tag:theconversation.com,2011:/us/topics/traumatic-brain-injury-7534/articlesTraumatic Brain Injury – The Conversation2024-02-28T12:34:47Ztag:theconversation.com,2011:article/2202672024-02-28T12:34:47Z2024-02-28T12:34:47ZLow-level blasts from heavy weapons can cause traumatic brain injury − 2 engineers explain the physics of invisible cell death<figure><img src="https://images.theconversation.com/files/574230/original/file-20240207-24-4417vk.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3500%2C2331&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Low-level blasts can cause physical changes in the brain.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/RussiaUkraineWarFrenchWeapons/0b650af49a654704a4bef82ae8a4bc93">Libkos/AP Photo</a></span></figcaption></figure><p>When the force of a blast shoots a round out of a large-caliber rifle, howitzer or M1 Abrams tank gun, the teams of people operating these weapons are exposed to <a href="https://health.mil/Reference-Center/Fact-Sheets/2023/07/18/Low-Level-Blast-Service-Members-Fact-Sheet">low-level blasts</a> that can cause <a href="https://www.brainline.org/qa/what-do-blast-injuries-do-your-brain">traumatic brain injuries</a>.</p>
<p>Low-level blasts do not cause visible trauma, such as bleeding from ruptured eardrums, and they don’t cause injury through violent head motion, such as a concussion. Yet, these blasts can cause <a href="https://pubmed.ncbi.nlm.nih.gov/27291520/">physical changes in the brain</a> that lead to a host of neuropsychiatric symptoms.</p>
<p>The link between the force of a blast and the resulting changes in the brain is not completely understood. So our team of <a href="https://scholar.google.com/citations?user=VlzdxcEAAAAJ&hl=en">engineers and</a> <a href="https://scholar.google.com/citations?user=aIl1GHoAAAAJ&hl=en">scientists in</a> the <a href="https://www.panther.engr.wisc.edu/">PANTHER program</a>, funded by the Department of Defense, is using physics to elucidate how blasts cause traumatic brain injury.</p>
<h2>What is a blast?</h2>
<p>When a weapon like a rifle <a href="https://www.hunter-ed.com/national/studyGuide/Video-How-a-Cartridge-Is-Fired/201099_92813/">is fired</a>, the round is initially in its barrel. Pulling the trigger engages a primer that produces a flame, igniting the propellant. This chemical reaction releases stored energy and creates high-pressure, rapidly expanding gas. This is the blast.</p>
<p>The rate and magnitude of gas expansion are often so extreme that they <a href="https://www.americanscientist.org/article/high-speed-imaging-of-shock-waves-explosions-and-gunshots">create a shock wave</a>, where high-pressure air molecules travel outward faster than the speed of sound. This invisible pulse of high pressure carries a tremendous amount of energy. It’s the same force that can propel a 24-pound warhead out of the muzzle of a howitzer to hit a target 19 miles (30.6 kilometers) away. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cross-section of a cartridge" src="https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/574231/original/file-20240207-29-yowd6.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This cross-section shows: 1. bullet; 2. case; 3. gunpowder; 4. rim; and 5. primer.</span>
<span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Cartridge_cross_section.svg">Glrx/Quadrell via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>After the blast leaves the gun’s muzzle, it dissipates quickly because it is free to expand in the open air. This is when the high pressure washes over the bodies of nearby people. </p>
<p>The blast from the muzzle of a large gun like the <a href="https://youtu.be/1anCHKq6ESg?feature=shared">M777 howitzer</a> does not pulverize rocks or knock someone off their feet. But some of the blast pressure enters the body, passing through the skin and rigid skull bone and into the soft tissue of the brain. </p>
<h2>Linking blast to brain injury</h2>
<p>As blast pressure enters the brain, it is initially compressive, meaning it squeezes the tissue equally from all sides. Because brain tissue is <a href="https://doi.org/10.1007/s11831-019-09352-w">largely composed of water molecules</a>, which are difficult to compress, this type of pressure <a href="https://link.springer.com/article/10.1007/s10439-019-02437-4">tends to cause little known harm</a> to cells. </p>
<p>An initially compressive wave, or positive pressure wave, that squeezes brain tissue changes when it bounces off the inside of the skull. It is reflected as a tensile wave, or negative pressure wave, which tends to pull brain tissue apart. With low enough pressures, <a href="https://doi.org/10.2217/cnc-2017-0011">micron-sized bubbles can form</a> in a process called cavitation. These bubbles can grow 10 to 50 times their initial size over the course of less than a tenth of a millisecond, rapidly stretching the adjacent brain tissue.</p>
<p>Experiments from our lab have shown that the deformation caused by cavitation bubbles happens so rapidly – like the speed of a bullet – that cells tend to <a href="https://www.sciencedirect.com/science/article/pii/S2666522021000149">get torn apart</a>. The extreme speed of stretching and squeezing causes nearby brain cells to die immediately. Afterward, we see only fragments where healthy cells used to be.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram showing blast pressure creating microbubbles in the brain after reflecting off surfaces, stretching and destroying cells in a process called cavitation." src="https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=454&fit=crop&dpr=1 754w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=454&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/577687/original/file-20240223-20-xi71p2.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=454&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This diagram depicts how blast pressure from a gun can result in brain trauma.</span>
<span class="attribution"><span class="source">Alice Lux Fawzi and Manik Bansal</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Cell death is the physical root cause of brain injury. In the lab, when the cells that make up brain tissue are deformed at a magnitude and rate beyond what they can withstand, they die – either immediately, as in the case of blast-induced cavitation, or slowly over six to 24 hours, as in most brain injuries from blunt impacts such as concussions. </p>
<p>In low-level blast exposure, the cavitation bubbles are very small, and the trauma is contained to the small area around them. However, repeated exposure to blasts can lead to an accumulation of these microtraumas, eventually reaching a volume large enough to cause significant and irreversible neurological symptoms. </p>
<p>Although evidence is mounting, it has yet to be fully proven that cavitation directly causes blast-induced traumatic brain injury. The hypothesis fits with <a href="https://pubmed.ncbi.nlm.nih.gov/27291520/">post-mortem analyses</a> of the brains of service members with a history of blast exposure. It also fits with the physics that link blast exposure to injury from tissue deformation. </p>
<p>Understanding the connection between blasts and cellular damage in the brain will help researchers develop better ways to protect against repetitive blast-induced traumatic brain injury.</p><img src="https://counter.theconversation.com/content/220267/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alice Lux Fawzi receives funding from the U. S. Office of Naval Research under the PANTHER Program.</span></em></p><p class="fine-print"><em><span>Christian Franck receives funding from the U.S. Office of Naval Research under the PANTHER program. </span></em></p>The people manning the guns are also at risk of injury from the force of the weapon.Alice Lux Fawzi, PANTHER Engineering Project Manager and Associate Director of the Center for Traumatic Brain Injury, University of Wisconsin-MadisonChristian Franck, Bjorn Borgen Professor of Mechanical Engineering and Director of the Center for Traumatic Brain Injury, University of Wisconsin-Madison, University of Wisconsin-MadisonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2142162023-11-14T13:25:01Z2023-11-14T13:25:01ZBrains have a remarkable ability to rewire themselves following injury − a concussion specialist explains the science behind rehabilitation and recovery<figure><img src="https://images.theconversation.com/files/558408/original/file-20231108-15-h36ch4.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C3594%2C2387&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Every brain injury is unique, as is every person's path to recovery. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/surgery-medical-team-surgical-doctor-teamwork-royalty-free-image/1218284504?phrase=concussion&adppopup=true">Chinnapong/iStock via Getty Images Plus</a></span></figcaption></figure><p>High-profile sports like football and soccer have <a href="https://theconversation.com/concussions-can-cause-disruptions-to-everyday-life-in-both-the-short-and-long-term-a-neurophysiologist-explains-what-to-watch-for-192390">brought greater attention in recent years</a> to concussions – the mildest form of <a href="https://www.cdc.gov/traumaticbraininjury/index.html">traumatic brain injury</a>. </p>
<p>Yet people often do not realize how common concussions are in everyday life, and seldom does the public hear about what happens in the aftermath of concussions – how long the road to recovery can be and what supports healing. Concussions are important to understand, not only for recovery, but also for the insights that the science of recovery can bring to brain health.</p>
<p>I am a speech language pathologist and an <a href="https://som.cuanschutz.edu/Profiles/Faculty/Profile/28113">instructor in physical medicine and rehabilitation</a>. I specialize in brain injury rehabilitation, with experience ranging from coma recovery to concussion care. </p>
<p>Treating problems tied to head injuries is complex. This is, in part, because it is not possible to directly examine the brain of a living person and because every brain injury is unique. Many aspects of health, both pre- and post-injury, affect recovery. In treating brain injuries, I work to translate this specialized science for each patient and their unique situation.</p>
<h2>Brain injury can take many forms</h2>
<p>While people commonly think of athletes when it comes to concussions, <a href="https://theconversation.com/the-risk-of-concussion-lurks-at-the-super-bowl-and-in-all-other-sports-176541">sports-related concussions</a> are just one type of mild brain injury seen in health care practice. Concussions can also result from <a href="https://ninds.nih.gov/health-information/disorders/traumatic-brain-injury-tbi">abusive head trauma, blast exposure, car accidents and falls</a>. </p>
<p>The severity of a brain injury is diagnosed based on symptoms, brain imaging and a neurologic exam. Concussions are characterized by a lack of clear tissue damage seen on <a href="https://my.clevelandclinic.org/health/diagnostics/22966-brain-mri">brain images like an MRI</a> and by the length of time that a person loses consciousness – defined as between zero to 30 minutes. </p>
<p>In addition, a significant portion of concussions <a href="https://doi.org/10.1136/bjsports-2012-091941">may not be identified or formally diagnosed at all</a>. Even if you do not lose consciousness at the time of an injury, you could still have a concussion. Confusion, sensitivity to noise and lights and even changes to sleep and mood are common symptoms. But often, these signs <a href="https://www.youtube.com/watch?v=P2wrNGrVHLk&t=11s">may be misunderstood as signs of stress or shock during traumatic events</a>, such as a car accident. Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/P2wrNGrVHLk?wmode=transparent&start=11" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Some people mistakenly assume that if they don’t lose consciousness, they haven’t experienced a concussion.</span></figcaption>
</figure>
<p>People who don’t feel that they have returned to normal after a concussion may need further treatment. Many report chronic symptoms that linger beyond the typical three-month recovery – a condition known as <a href="https://www.mayoclinic.org/diseases-conditions/post-concussion-syndrome/symptoms-causes/syc-20353352#">post-concussive syndrome</a>. Around 10% of those who suffer a concussion experience post-concussive syndrome, although differences in how this problem is defined and recorded leads to <a href="https://doi.org/10.3171/2015.6.JNS15664">highly variable estimates across studies</a>.</p>
<p>So how does having a concussion affect the brain over time? </p>
<p>The links between concussion and dementias such as chronic traumatic encephalopathy, or, more generally, the relationship between a brain injury early in life and later brain diseases, are <a href="https://doi.org/10.1093/brain/awz286">not yet clear</a>. </p>
<p>This uncertainty should not stop people from <a href="https://doi.org/10.1002%2Fana.26566">finding a path forward</a> and taking strides to support their own brain health. </p>
<h2>The brain’s mode of repair</h2>
<p>After recovering from a brain injury, patients want to understand how to minimize further risk to their brain, which is all the more important since prior injury puts the brain at <a href="https://pubmed.ncbi.nlm.nih.gov/14625331/">greater risk for further injuries</a>.</p>
<p>Researchers and medical providers have learned that after injury the brain can change and “rewire” itself at a cellular level over the life span – a process called <a href="https://www.ncbi.nlm.nih.gov/books/NBK557811/#">neuroplasticity</a>. Brain cells, called neurons, join to form electrical pathways that power activity within the brain. In addition to other repair processes, neuroplasticity supports damaged brain areas to reconnect injured routes or find “detours” to restore brain function. This means that in recovery, the brain can literally find a new way – or make one – to regain critical abilities.</p>
<p>Neuroplasticity also offers insight into why each brain injury is unique. </p>
<p>Following a concussion, therapists focus on <a href="https://doi.org/10.46747%2Fcfp.6803175">detailed evaluations and patient interviews</a> to identify affected areas and to design an intervention. While the general map of <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain">brain regions and their associated functions is standard</a>, individual variability is common. Brain injuries from the same cause of injury, via similar force and intensity of impact and affecting the same location of the brain, can lead to very different symptoms in different people. </p>
<p>While the brain is fully developed by the time people reach their early 20s, neuroplasticity continues well beyond this point. Researchers have seen neuroplastic change during the life span in both <a href="https://theconversation.com/youve-likely-heard-of-the-brains-gray-matter-heres-why-the-white-matter-is-important-too-180945">the white</a> and <a href="https://doi.org/10.1038/nn.3045">gray matter</a> that form brain tissue. The remapping of brain pathways that occurs in <a href="https://doi.org/10.1016/j.apmr.2011.03.036">late-life injuries, such as a stroke</a>, is one strong piece of evidence to suggest there may be no specific “end date” to the brain’s capacity to restore its internal connections. </p>
<p>Importantly, fuller density of brain cells is thought to create a buffer that is protective against damage due to injury and aging. This extra “bandwidth” is referred to as <a href="https://doi.org/10.1016/j.neuropsychologia.2009.03.004">cognitive reserve</a>. Broadly speaking, higher levels of baseline cognitive reserve have been linked to <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002259">genetics, educational attainment and health factors</a>.</p>
<p>Neuroplasticity is one process that research shows is critical to maintaining these reserves throughout life.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/-akOXNcuql8?wmode=transparent&start=51" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">One high-profile study found that nearly half of all people who experienced a concussion were still experiencing symptoms half a year later.</span></figcaption>
</figure>
<h2>Building and maintaining your cognitive reserves</h2>
<p>Cognitive reserve is crucial to brain health both before and after a concussion. </p>
<p>Studies show that <a href="https://doi.org/10.1016/j.apmr.2019.08.477">higher levels of cognitive reserve</a> may lessen your risk for prolonged problems after a concussion. In addition, injuries that occur <a href="https://doi.org/10.1177/1941738112473059">during childhood</a> and <a href="https://doi.org/10.1016/j.ajem.2021.11.005">late life</a> may present different challenges in recovery linked to the brain’s cognitive reserves and overall health.</p>
<p>For this reason, <a href="https://www.ncbi.nlm.nih.gov/books/NBK185341/">screening tools for concussion</a> often probe a person’s medical history prior to the event.</p>
<p>Keeping up cognitive reserves likely maintains healthy brain connections that can help us age better. <a href="https://doi.org/10.1002/hbm.25605">Bilingualism</a>, maintaining an <a href="https://www.aan.com/PressRoom/Home/PressRelease/5006">active social life</a> and even <a href="https://www.aan.com/PressRoom/Home/PressRelease/5006">going to museums</a> are linked with lower rates of dementia. These studies support that brain activity is good for brain health and it is triggered by many things, including thinking, learning and engaging with the world around us. </p>
<h2>How daily activity rewires the brain</h2>
<p>Just as there is no one-size-fits-all brain injury, there is also no single path toward brain health. </p>
<p>Advanced <a href="https://doi.org/10.3389%2Ffneur.2021.639179">brain imaging to detect concussions</a> is not available in standard clinical settings, so clinicians rarely have clear road maps for rehabilitation. But getting optimal sleep, avoiding excessive drinking or other toxic substances and leading a physically and mentally active life are core tenets of brain health. </p>
<p>Finally, the brain does not exist in isolation. Its health is connected to other parts of the body in many ways. Therefore, doctors recommend treating medical conditions that <a href="https://doi.org/10.1001/jamaneurol.2022.0976">directly affect our brain health and that reduce brain aging</a>, such as <a href="https://doi.org/10.1161/HYPERTENSIONAHA.110.163055">high blood pressure</a>,<a href="https://doi.org/10.1002/alz.057893">sleep apnea</a>,<a href="https://doi.org/10.1186/s10194-020-01166-7">migraines</a> and even <a href="https://doi.org/10.1016/S2468-2667(23)00058-0">hearing loss</a>.</p>
<p>Brain health is unique to each person, and brain injury treatment depends on your individual lifestyle and health risks. Strategies to treat <a href="https://doi.org/10.1093%2Fneuros%2Fnyz332">specific symptoms vary</a> and should be designed with the help of medical specialists. But brain health and cognitive reserve provide a common direction for everyone. Living an active lifestyle – physically, mentally and socially – can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586385/">drive neuroplasticity and maintain the brain</a>.</p>
<p>Studies of healthy people offer insights into how individual brains are shaped through everyday activities. For instance, research finds that <a href="https://doi.org/10.3410%2FB1-78">expert musicians</a> have denser sound-processing regions in their brains. The brains of cab drivers have <a href="https://doi.org/10.1073/pnas.070039597">greater development of spatial memory areas</a>. Even military fighter pilots have been shown to have <a href="https://doi.org/10.3389/fphys.2023.1082166">denser tissue in regions connected to strategic thinking</a>. </p>
<p>These startling discoveries teach us that what we do every day truly matters to brain health. For all of these reasons, brain researchers commonly use the phrase <a href="https://doi.org/10.1098%2Frstb.2013.0175">“neurons that fire together, wire together”</a> to describe how the brain’s connections change shape associated with repeated patterns of the electrical firing of brain activity. </p>
<p>While many questions remain to be answered, it is well established that the brain can be shaped throughout life. With this knowledge in mind, we can tend to it with greater care.</p><img src="https://counter.theconversation.com/content/214216/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hilary works in brain rehabilitation and references her clinic in this article. The arguments provided in this article may lead readers to seek brain-related healthcare. Hilary has a professional relationship with two of the authors who works are included in cited research. </span></em></p>Concussions can teach researchers a great deal about how the brain recovers after injury and offer insights into how people can promote brain health throughout their lives.Hilary A. Diefenbach, Speech Language Pathologist and Cognitive Rehabilitation Specialist, Marcus Institute for Brain Health; Instructor, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2123692023-08-29T01:36:06Z2023-08-29T01:36:06ZNew study highlights the brain trauma risks for young athletes<figure><img src="https://images.theconversation.com/files/544981/original/file-20230828-245330-4v4rcf.jpg?ixlib=rb-1.1.0&rect=4%2C0%2C3197%2C2136&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/australian-rules-youths-leaping-take-mark-4816717">Shutterstock</a></span></figcaption></figure><p>The <a href="https://www.bu.edu/articles/2023/young-amateur-athletes-at-risk-of-cte-study-finds/">Boston University CTE Center</a> today reported the results of the largest-ever study of chronic traumatic encephalopathy (CTE) in young athletes. </p>
<p>The <a href="https://jamanetwork.com/journals/jamaneurology/fullarticle/2808952?resultClick=1">study</a>, examining autopsied tissue, found signs of CTE in 63 out of 152 young athlete brains. The subjects of the study competed in youth, high school and college competitions, and all died before the age of 30. </p>
<p>This case series includes the first American woman athlete diagnosed with the disease, just months after the Australian Sports Brain Bank reported the <a href="https://theconversation.com/australian-researchers-confirm-worlds-first-case-of-dementia-linked-to-repetitive-brain-trauma-in-a-female-athlete-208929">world’s first</a> case of CTE in a female athlete.</p>
<p>The results of this study have major implications for sporting leagues around the globe. Like other dementias, CTE is often assumed to be a disease that develops later in life, but as neuropathologist and Boston University CTE Centre Professor Ann McKee says, “this study clearly shows that the pathology of CTE starts early”. </p>
<p>These latest findings come as Australia’s Senate is due to <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport">report</a> the findings of its inquiry into concussions and repeated head trauma in contact sport. </p>
<p>This should push sporting organisations to do more to protect the brains of all athletes, especially in junior and recreational competitions.</p>
<h2>CTE and young athletes</h2>
<p><a href="https://www.mayoclinic.org/diseases-conditions/chronic-traumatic-encephalopathy/symptoms-causes/syc-20370921">CTE</a> is a devastating and currently incurable form of dementia which causes <a href="https://www.frontiersin.org/articles/10.3389/fneur.2022.938163/full">neurodegeneration of the brain</a>. The disease has <a href="https://www.frontiersin.org/articles/10.3389/fspor.2021.676463/full">long</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987576/">been</a> associated with contact sport participation. </p>
<p>Dementias like CTE are often thought of as diseases of the elderly. However, some high-profile cases of CTE have been identified among younger athletes. </p>
<p>In Australia, much-loved NRL player and coach <a href="https://www.abc.net.au/news/2022-10-22/qld-paul-green-brain-scans-reveal-brain-disease-cte-diagnosis/101566032">Paul Green</a> was 49 when he died and was later found to have CTE. Former AFL star <a href="https://www.theguardian.com/sport/2023/mar/01/nrl-and-football-australia-accept-link-between-head-trauma-and-cte">Shane Tuck</a> was 38 when he died with the disease. Former AFLW player <a href="https://www.abc.net.au/news/2023-07-04/cte-diagnosis-in-female-athlete-heather-anderson-aflw-730/102555944">Heather Anderson</a> was only 28. A <a href="https://www.bu.edu/cte/our-research/case-studies/18-year-old/">recent study</a> in the United States also found CTE in the brain of an 18-year-old athlete. </p>
<p>The disease is <a href="https://www.mayoclinic.org/diseases-conditions/chronic-traumatic-encephalopathy/symptoms-causes/syc-20370921">known</a> to cause mood disorders and behaviour changes. People with CTE may be at higher risk of suicide. </p>
<p>These cases and the latest Boston University study indicate the risk of developing CTE is not restricted to those in their middle or older years. Although there is some evidence <a href="https://pubmed.ncbi.nlm.nih.gov/27552147/">developing brains are more vulnerable to trauma</a> – it creates a chronic inflammatory response affecting brain development – the pathology of CTE is still being studied.</p>
<p>The <a href="https://www.nejm.org/doi/full/10.1056/NEJMclde2302021">risk factors for young athletes</a> are complex and multifaceted but it is likely that playing junior contact sport heightens an athlete’s risk of developing neurodegenerative diseases as an adult.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1675987912066727936"}"></div></p>
<p>The strongest <a href="https://www.nature.com/articles/s41467-023-39183-0">predictor</a> for developing CTE is cumulative exposure to repeated brain trauma, rather than the number of diagnosable concussions. Prolonged exposure to repeated low-level impacts appears to produce a greater lifetime volume of brain trauma when compared with athletes who sustain a small number of more forceful injuries.</p>
<p>Again, the reasons for this dynamic require further study. One potential explanation is that low-level impacts, which often do not reach the <a href="https://www.concussioninsport.gov.au/medical_practitioners#assessment_of_concussion">clinical threshold</a> for a concussion diagnosis, are easier to ignore and play through. </p>
<p>For the athletes in the Boston University study to develop CTE before the age of 30, it is likely they were exposed to repeated brain trauma from an early age through youth sport.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australian-researchers-confirm-worlds-first-case-of-dementia-linked-to-repetitive-brain-trauma-in-a-female-athlete-208929">Australian researchers confirm world’s first case of dementia linked to repetitive brain trauma in a female athlete</a>
</strong>
</em>
</p>
<hr>
<h2>Are contact sports safe for kids?</h2>
<p>Public health advocates in <a href="https://www.cambridge.org/core/journals/journal-of-law-medicine-and-ethics/article/abs/youth-sports-public-health-framing-risks-of-mild-traumatic-brain-injury-in-american-football-and-ice-hockey/1529848D096AD28A080B3EE828E7E553">North America</a>, <a href="https://www.frontiersin.org/articles/10.3389/fneur.2022.880905/full">Australia</a>, <a href="https://www.stuff.co.nz/sport/129063074/new-zealands-teenage-concussion-issue-rugby-pushes-for-national-guidelines-to-erase-blurred-lines">New Zealand Aotearoa</a> and the <a href="https://pubmed.ncbi.nlm.nih.gov/25586912/">United Kingdom</a> have long expressed concerns about the risks of contact sport for children. </p>
<p>Improved oversight would go some way toward reducing the serious health risks of mild traumatic brain injury (concussion). These include <a href="https://concussionfoundation.org/PCS-resources/what-is-PCS#:%7E:text=Post%2DConcussion%20Syndrome%2C%20or%20PCS,may%20diagnose%20Post%2DConcussion%20Syndrome">post-concussion syndrome</a> (where symptoms do not resolve within the expected time period of about one month) and <a href="https://www.ncbi.nlm.nih.gov/books/NBK448119/">second impact syndrome</a> (where a young athlete who has previously been concussed receives a second impact either on the same day or up to a week later, resulting in catastrophic outcomes).</p>
<p>Although professional athletes are increasingly subject to monitoring for brain injuries, these practices are not consistently in place for participants in <a href="https://theconversation.com/repeated-head-injury-may-cause-degenerative-brain-disease-for-people-who-play-sport-juniors-and-amateurs-included-196042">semi-professional, club or junior competitions</a>. It is essential that sports bodies implement the same reporting, monitoring and exclusion protocols all the way through their competitions, especially in junior sport.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&rect=40%2C0%2C6669%2C3098&q=45&auto=format&w=1000&fit=clip"><img alt="young players huddle on sporting field" src="https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&rect=40%2C0%2C6669%2C3098&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=282&fit=crop&dpr=1 600w, https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=282&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=282&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=354&fit=crop&dpr=1 754w, https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=354&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/544979/original/file-20230828-189469-cedpkj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=354&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Some codes have introduced restrictions to protect young players.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/kids-sport-team-gathering-rising-hands-1682342155">Shutterstock</a></span>
</figcaption>
</figure>
<h2>First steps</h2>
<p>Existing concussion guidelines are not designed to account for the types of sub-concussive injuries (where an impact does not result in observable symptoms) most strongly associated with CTE. To protect them from the disease, contact sporting bodies must reduce young athletes’ lifetime exposure to brain trauma. One way to do this would be to restrict contact in training and games for juniors. </p>
<p>Some sporting bodies have already taken the initial steps. <a href="https://www.play.afl/play/junior-football-rules">Australian Rules football players</a> are restricted to modified tackling until the age of 12. The <a href="https://www.playrugbyleague.com/framework/tackleready/">National Rugby League</a> will soon implement a ban on tackling until midway through under-7s competitions. </p>
<p>The US Soccer Federation <a href="https://www.nytimes.com/2015/11/10/sports/soccer/us-soccer-resolving-lawsuit-will-limit-headers-for-youth-players.html">prohibits</a> children under 11 from heading the ball. The UK Football Association will trial <a href="https://www.thefa.com/news/2022/jul/18/statement-heading-trial-u12-games-20221807#:%7E:text=The%20FA%20has%20been%20granted,of%20the%202022%2D23%20season.">a ban on deliberate heading</a> before age 12 – a clear acknowledgement of the dangers of repetitive low-grade brain trauma. </p>
<p>The prevalence of CTE in this study from the US, where athletes routinely wear helmets to play football and ice hockey, is further evidence helmets do not protect young players from concussions or the risk of CTE. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-women-soccer-players-have-more-concussions-this-world-cup-and-beyond-heres-how-to-keep-our-players-safe-208292">Do women soccer players have more concussions? This world cup and beyond, here's how to keep our players safe</a>
</strong>
</em>
</p>
<hr>
<p>Changes to tackling rules were met with resistance by those who <a href="https://www.dailymail.co.uk/sport/rugbyleague/article-11746861/Is-rugby-league-going-soft-Controversial-changes-NRL-leave-parents-fuming.html">fear</a> they would “soften” the games. Further measures to protect athletes will require courage from contact sports administrators.</p>
<p>This new study shows CTE can develop in young brains and builds off previous research suggesting the origins of this pathology may lie in junior contact sport. To protect players from neurodegenerative diseases like CTE, sports must <a href="https://concussionfoundation.org/sites/default/files/2023-06/CTE%20prevention%20protocol%20062023.pdf">reduce cumulative exposure to brain trauma</a> for all athletes, beginning with the junior leagues. In Australia, where children have at least four football codes to choose from, this message must be received with particular urgency.</p>
<hr>
<p><em>If this article has raised issues for you, or if you’re concerned about someone you know, call <a href="https://www.lifeline.org.au/">Lifeline</a> on 13 11 14. The National Dementia Helpline number is 1800 100 500.</em></p><img src="https://counter.theconversation.com/content/212369/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alan Pearce is currently unfunded. Alan is a non-executive unpaid director for the Concussion Legacy Foundation. He has previously received funding from Erasmus+ strategic partnerships program (2019-1-IE01-KA202-051555), Sports Health Check Charity (Australia), Australian Football League, Impact Technologies Inc., and Samsung Corporation, and is remunerated for expert advice to medico-legal practices.</span></em></p><p class="fine-print"><em><span>Kathleen Bachynski is a member of the Pink Concussions professional advisory board.
</span></em></p><p class="fine-print"><em><span>Stephen Townsend does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Chronic traumatic encephalopathy is often assumed to be a disease which develops later in life, but a new study clearly shows it can start early in the brains of young athletes.Stephen Townsend, Lecturer, School of Human Movement and Nutrition Sciences, The University of QueenslandAlan Pearce, Professor, College of Science, Health, Engineering, La Trobe UniversityKathleen Bachynski, Assistant Professor, Public Health, Muhlenberg CollegeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2082922023-07-19T23:55:57Z2023-07-19T23:55:57ZDo women soccer players have more concussions? This world cup and beyond, here’s how to keep our players safe<p>The 2023 FIFA Women’s World Cup starts today, and more teams are <a href="https://www.fifa.com/fifaplus/en/articles/everything-you-need-to-know-about-about-the-fifa-womens-world-cup-2023">taking part</a> than ever before. The number of women and girls playing soccer around the world has also increased from about <a href="https://www.icsspe.org/system/files/FIFA%20-%20Womens%20Football%20Survey.pdf">five million in 2014</a> to more than <a href="https://img.fifa.com/image/upload/nq3ensohyxpuxovcovj0.pdf">13 million in 2019</a>. </p>
<p>This greater participation in soccer over the years has led to an increase in injuries, including <a href="https://pubmed.ncbi.nlm.nih.gov/24739186/">concussions</a>. These can follow a range of situations, such as when the head hits the ball, players’ heads collide, or when the head hits the ground or goalpost.</p>
<p>But are women more at risk than men from such concussions? And if so, why? Here’s what the evidence says.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australian-researchers-confirm-worlds-first-case-of-dementia-linked-to-repetitive-brain-trauma-in-a-female-athlete-208929">Australian researchers confirm world’s first case of dementia linked to repetitive brain trauma in a female athlete</a>
</strong>
</em>
</p>
<hr>
<h2>What is concussion?</h2>
<p>Concussion is a mild traumatic brain injury that usually happens when someone’s head hits something or someone. But it can also happen after being hit on the body, causing a whiplash-type motion to the head. </p>
<p>Common symptoms include headache, dizziness and fatigue. Most soccer players <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/sms.13644">return to play</a> within four weeks of a concussion. Although an estimated 10% of players (particularly women) will have persisting symptoms lasting several months.</p>
<p>Concussions are <a href="https://pubmed.ncbi.nlm.nih.gov/30892095/">twice</a> as likely to occur in games rather than in practice sessions. Defenders and goalkeepers have <a href="https://www.tandfonline.com/doi/abs/10.1080/00913847.2020.1868955?journalCode=ipsm20">more concussions</a> than forwards or midfielders.</p>
<p>Concussion is more likely as a result of contact between the head and an opponent’s elbow or shoulder, head-to-head contact, or contact of the head with the ground or goalpost.</p>
<p>Contact between players (whether head-to-head or elbow-to-head) is more common during a <a href="https://www.tandfonline.com/doi/full/10.3109/02699052.2013.865269">heading duel</a> – when two or more players compete for a ball in the air.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hit-your-head-while-playing-sport-heres-what-just-happened-to-your-brain-203038">Hit your head while playing sport? Here's what just happened to your brain</a>
</strong>
</em>
</p>
<hr>
<h2>When the ball hits the head</h2>
<p>Heading the ball, when players intentionally use their heads to redirect the ball, is unique to soccer. But concussion is <a href="https://pubmed.ncbi.nlm.nih.gov/30760457/">more likely</a> after the ball hits the head accidentally.</p>
<p>Regardless of whether such an impact is intentional, there is increasing concern that players exposed to repeated head impacts in soccer, including from headers, are <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00027-0/fulltext">more at risk</a> of developing neurodegenerative diseases, such as dementia, in later life.</p>
<p>But current evidence for this only exists in men. In Australia (and other countries), soccer was deemed “<a href="https://www.footballaustralia.com.au/history-womens-football-australia">medically inappropriate</a>” for women until the 1970s. So not only have fewer women played soccer historically, their game hasn’t been so well researched.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/will-australia-receive-a-red-card-for-gender-equity-at-the-2023-womens-world-cup-196276">Will Australia receive a red card for gender equity at the 2023 Women's World Cup?</a>
</strong>
</em>
</p>
<hr>
<h2>Are women more at risk?</h2>
<p>In soccer, and other sports where men and women participate under the same rules, women appear to have much <a href="https://journals.sagepub.com/doi/10.1177/2325967120932306">higher rates</a> of concussion compared to men. </p>
<p>For every 1,000 hours of playing or practising soccer, <a href="https://bjsm.bmj.com/content/43/Suppl_1/i46.short">there are</a> about 1.5 concussions for women compared with 1.0 for men.</p>
<p>Women <a href="https://meridian.allenpress.com/jat/article/51/3/189/112725/Sex-Differences-in-Reported-Concussion-Injury">report</a> greater number of symptoms, increased symptom intensity and greater time lost from sport after a concussion.</p>
<p>Concussions caused by ball-to-head contact is also much <a href="https://bjsm.bmj.com/content/43/Suppl_1/i46">more common</a> in women and girls, than in men.</p>
<p>So what might be happening in soccer? To answer this, we need to look at <a href="https://www.sciencedirect.com/science/article/pii/S1466853X21001231#bib57">several factors</a>, some biological, some related to how women are trained.</p>
<h2>1. Neck strength</h2>
<p>Women soccer players generally have <a href="https://www.sciencedirect.com/science/article/pii/S1440244019306607?via%3Dihub">weaker neck muscles</a> than men. This may place them at higher risk of concussion if they cannot engage these muscles to <a href="https://link.springer.com/article/10.1007/s40279-021-01501-1">stabilise</a> their head if it is hit by another head, body or the ball. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sports-concussions-affect-men-and-women-differently-female-athletes-need-more-attention-in-brain-research-160097">Sports concussions affect men and women differently. Female athletes need more attention in brain research</a>
</strong>
</em>
</p>
<hr>
<h2>2. Hormones</h2>
<p>The female sex hormones oestrogen and progesterone <a href="https://journals.lww.com/headtraumarehab/Fulltext/2014/09000/Menstrual_Phase_as_Predictor_of_Outcome_After_Mild.11.aspx">may protect</a> women from sustaining a concussion.</p>
<p>Half of concussions also take place in the part of the menstrual cycle known as the late “luteal phase”. This is a seven-day window when oestrogen and progesterone levels are declining. However, the research is too limited to speculate further on the role of sex hormones.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/period-shame-stops-countless-girls-from-continuing-sport-the-womens-world-cup-can-help-break-this-stigma-205570">Period shame stops countless girls from continuing sport. The Women’s World Cup can help break this stigma</a>
</strong>
</em>
</p>
<hr>
<h2>3. Training</h2>
<p>Women and girls are less likely than men and boys to be trained in how to head the ball, according to an <a href="https://www.tandfonline.com/doi/full/10.1080/24733938.2023.2224282">Australian survey</a> of players and coaches. Adolescent players without this training are <a href="https://meridian.allenpress.com/jat/article/doi/10.4085/1062-6050-0340.22/490251/The-effect-of-neuromuscular-injury-reduction">more likely</a> to report concussion.</p>
<p>Most concussions in soccer occur when two players compete to head the ball. Here, their heads and arms are more likely to make contact, leading to concussion, rather then concussion resulting from hitting the ball itself.</p>
<p>So training players to safely head the ball should include how to position the body to minimise the risk of injury and keeping the eyes open to track the ball’s trajectory to prepare for ball-to-head contact. </p>
<p>But 90% of women close their eyes when heading a ball compared to 79% of men, according to <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306987716308325">one report</a>. This potentially reduces a player’s readiness for ball contact, and makes them less aware of any players around them. As a result, they are less able to protect their head against an opponent’s elbow or head. However, further research is needed to understand the role of players having their eyes open or shut, and the risk of concussion.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/goooooooal-new-research-on-the-best-way-to-score-at-the-womens-world-cup-118117">Goooooooal! New research on the best way to score at the Women's World Cup</a>
</strong>
</em>
</p>
<hr>
<h2>How do we reduce the risk?</h2>
<p>Guidelines <a href="https://link.springer.com/article/10.1007/s40279-023-01852-x">published</a> last month aim to reduce the numbers of headers in soccer. These approaches are also likely to decrease the number of header duels, a common mechanism of concussion, as well as the long-term risks associated with ball-to-head impacts.</p>
<p>Recommended strategies include:</p>
<ul>
<li><p><strong>fewer players, smaller goals</strong> – small-sided play (for example five-a-side or seven-a-side) during matches and training for younger, beginner players, plus smaller goals, reduces the number of balls in the air, and headers</p></li>
<li><p><strong>playing out from the back</strong> – passing the ball out from the goalkeeper to defenders rather than kicking it long the pitch leads to less high-force headers from goal kicks</p></li>
<li><p><strong>short corner kicks</strong> – kicking the ball from a corner kick to a close-by team-mate is less likely to lead to header duels around the goal</p></li>
<li><p><strong>neck exercises</strong> – to prepare the neck muscles for heading, neck exercises can be added to injury prevention programs. These can <a href="https://link.springer.com/article/10.1007/s40279-021-01564-0">reduce</a> head acceleration and potential concussion in adolescent players</p></li>
<li><p><strong>red cards</strong> – enforcing red cards (being sent off the pitch) for deliberate head contact <a href="https://pubmed.ncbi.nlm.nih.gov/28646098/">reduces the number</a> of concussions.</p></li>
</ul>
<p><a href="https://www.tandfonline.com/doi/full/10.1080/24733938.2023.2224282">Under 5%</a> of the 211 soccer associations around the world endorse heading guidelines. So now is the ideal time to explore strategies that keep all soccer’s positive benefits while minimising the risk to current and future generations of players.</p><img src="https://counter.theconversation.com/content/208292/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shreya Mcleod is a Lecturer and Course Coordinator in Physiotherapy at Australian Catholic University. She is a PhD Candidate at the University of Newcastle, researching concussion in women's contact and collision sports. She is also a Titled Sports and Musculoskeletal Physiotherapist and currently contracts with Cricket NSW. She has previously been a Contract Physiotherapist for Cricket Australia, Hobart Hurricanes WBBL, Singapore Sports Council and the WTA. </span></em></p><p class="fine-print"><em><span>Kerry Peek is a senior lecturer (physiotherapy) and sports injury researcher from the University of Sydney. Kerry has received funding from a FIFA Research Scholarship and from Sports Medicine Australia. Kerry is currently an injury spotter (concussion) for FIFA organised tournaments (2023: U20s Men's World Cup and Women's World Cup). Kerry is a member of UEFA’s Heading Expert Group and Football Australia’s Expert Working Group (Heading and Concussion).</span></em></p>Many concussions in soccer occur when two players compete to head the ball. But extra technique training, modifying how we play the game, and more ‘red cards’ help cut the risk.Shreya Mcleod, Course Coordinator & Lecturer, Physiotherapy, Australian Catholic UniversityKerry Peek, Senior Lecturer in Physiotherapy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2054592023-06-23T12:28:26Z2023-06-23T12:28:26ZProcessing and grieving an ongoing loss – such as a child with a devastating injury or disability – does not fit neatly into traditional models of grief<figure><img src="https://images.theconversation.com/files/530974/original/file-20230608-19-z5aye.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C8449%2C5472&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Loss without a clear resolution can be particularly painful.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/dont-keep-it-all-bottled-up-royalty-free-image/658442986?phrase=upset+person&adppopup=true">laflor/iStock via Getty Images Plus</a></span></figcaption></figure><p>Traditional loss is <a href="https://www.cnn.com/2021/09/12/health/five-stages-of-grief-kubler-ross-meaning-wellness/index.html#:%7E">typically considered a five-stage process</a>, linear and time-bound, where a person moves from denial to acceptance. </p>
<p>Generally, traditional loss is linked to death – such as the death of a loved one, or a miscarriage. It is permanent, often abrupt, occurring when someone or something once present is suddenly absent. </p>
<p>But loss is complex. Other kinds of loss do not follow the one-size-fits-all archetype, and many experts now <a href="https://doi.org/10.3389%2Ffpsyg.2021.772696">criticize the five stages of grief model</a>. </p>
<p><a href="https://directory.hsc.wvu.edu/Profile/54223">As a nursing professor</a> who researches the impact of childhood illness on family well-being, one of my main areas of study is how people navigate another type of loss – ambiguous loss, or loss without closure.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uHFq6v8AiOo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Ambiguous loss, or loss without closure, is a unique kind of trauma.</span></figcaption>
</figure>
<h2>Coping with absence, letting go</h2>
<p>Ambiguous loss is <a href="https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/coping-with-ambiguous-grief">something that’s ongoing, recurring or unresolved</a>. The loved one is still alive but different from who they once were. </p>
<p>For over a decade, I have worked with hundreds of parents who became caregivers to once-healthy children who sustained a devastating injury or illness. Perhaps the child has a traumatic brain injury, resulting from a car accident or a near drowning. Or they were born with progressive disabilities resulting in the need for specialized, long-term care.</p>
<p>In these instances, the caregiver is not only coping with the absence of what was but letting go of what could have been. </p>
<p>As one parent said to me: “You have all these dreams for your child. Sometimes with disabilities those things will never happen. Reevaluating expectations is challenging and a little sad.” </p>
<p>Because of the ambiguity of these types of experiences, nothing – no model, no set number of stages – can fully prepare parents to navigate this type of loss. </p>
<p>But although ambiguous loss differs from traditional loss, researchers still lump the two together. That is why studies on ambiguous loss are scarce, and there is no formula to help <a href="https://doi.org/10.1080/01463373.2020.1759112">the caregivers manage their grief</a>.</p>
<p>Until researchers abandon their traditional view of loss, we won’t fully understand how to help those experiencing ambiguous loss. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/fSBqtkyl-Qs?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How a child injured in the 2013 Boston Marathon bombing dealt with ambiguous loss.</span></figcaption>
</figure>
<h2>Finding meaning in loss</h2>
<p>During the 1960s, psychiatrist Viktor Frankl <a href="https://www.pbs.org/wgbh/questionofgod/voices/frankl.html">developed the concept of “Will to Meaning</a>,” based on his experience as a Holocaust survivor in Nazi concentration camps during World War II. </p>
<p>Frankl saw some prisoners in the camp keep a positive attitude and wondered how they did it in such a treacherous environment. He came to understand that humans have the ability to choose how they perceive their experiences. Finding meaning, he learned, <a href="https://doi.org/10.1007/BF01532076">helps people persevere through their suffering</a>. </p>
<p>In the 1980s, Frankl’s concepts were adapted into the “<a href="https://doi.org/10.5964/ejop.5439">theory of meaning</a>” – <a href="https://www.viktorfranklinstitute.org/personnel/patricia-starck/">essentially a guide for nurses</a> on how to help patients find meaning and purpose after an unprecedented loss. Nurses discovered that an individual’s active, personal decisions could alter that person’s perception of these traumatic experiences.</p>
<p>That theory of meaning proved to be a beacon of hope for people in difficult situations. For decades, nurses throughout the world have used this concept to <a href="https://doi.org/10.14475/kjhpc.2017.20.4.221">reach out to countless numbers of patients</a>, particularly those who have cancer, spinal cord injuries, drug or alcohol addictions, or those in hospice care. </p>
<p>But I believe my work is the first of its kind to use the theory of meaning to interact <a href="https://journals.lww.com/advancesinnursingscience/Abstract/9900/Caring_for_a_Child_With_an_Acquired_Disability_.58.aspx">with parents experiencing ambiguous loss</a>. I interviewed eight parents of children with an acquired disability – mostly traumatic brain injuries – to better understand whether they were able to find meaning in their loss. </p>
<p>I found that parents were experiencing profound suffering because they were on edge, worried about lifelong care for their child and unaware of the consequences of loss. This suffering reached every family member and led to strained marital relationships, depression, anxiety, anger, sleep deprivation and fear of the unknown. </p>
<p>However, parents overcame these challenges by providing care to their child and creating a space to connect to family, friends and other parents undergoing similar experiences. They found joy in their child’s smallest success. The result was deeper relationships within their family and a hopeful outlook for the future. </p>
<p>One parent told me: “There’s nothing that’s ever been harder … but caring for (my child) is the most rewarding thing I’ve ever done with my life.” Another said: “He has overcome so much, and our family has grown because of what we’ve experienced.”</p>
<p>It’s clear these parents didn’t just move through the traditional stages of denial, anger, bargaining, depression and acceptance. Surely these broad emotions and feelings were likely present, probably even all at once. But they were able to choose how they perceived their experiences – to find purpose in their caregiving regardless of the disability. </p>
<p>These parents didn’t simply accept their loss as the traditional model describes, but transformed it into something meaningful to help them persevere through their experiences. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ge1r48D2bvM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Ambiguous loss can happen to caregivers when their elderly parent has dementia.</span></figcaption>
</figure>
<h2>How to help</h2>
<p>What these parents often <a href="https://doi.org/10.1080/09638288.2021.1946176">lack is community-based support</a>, such as respite care, transportation, financial aid and support groups. This helps parents meet basic needs so they can take care of themselves, reflect on their experiences more clearly and find meaning to push them forward.</p>
<p>During a time of ambiguous loss, parents say their lives have turned upside down; they are trying to navigate a new normal. They feel isolated, lonely, misunderstood and judged. </p>
<p>If you know someone experiencing ambiguous loss, it helps to simply ask them how they’re doing. You might offer to bring them dinner, include them in activities or just sit with them and listen. These simple acts of kindness may help them feel better understood – and reinvigorate their purpose to face another day.</p><img src="https://counter.theconversation.com/content/205459/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brad Phillips does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Letting go of what could have been is a critical step in handling ambiguous loss.Brad Phillips, Assistant Professor of Nursing, West Virginia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045282023-06-19T20:00:41Z2023-06-19T20:00:41ZGenetics and concussion – why a minor knock can be devastating for some people<figure><img src="https://images.theconversation.com/files/528968/original/file-20230530-38788-uxzrwj.jpg?ixlib=rb-1.1.0&rect=30%2C7%2C5081%2C2682&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-young-caucasian-sports-athlete-having-471119147">Shutterstock</a></span></figcaption></figure><p>Concussion and head trauma is a real and serious risk for many Australians. While most people suffer acute and relatively short-lived effects, such as dizziness and headache, in some cases symptoms persist for weeks, months or years. It can result in long-term and debilitating neurological impairment. </p>
<p>Concussion in sport – from the junior to the elite level – is being prioritised as a public health concern in Australia. A <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport">Senate inquiry</a> into concussions and repeated head trauma in contact sport is due to report in August. Of note in the hearings has been the AFL’s <a href="https://parlinfo.aph.gov.au/parlInfo/download/committees/commsen/26756/toc_pdf/Community%20Affairs%20References%20Committee_2023_04_26.pdf;fileType=application%2Fpdf#search=%22committees/commsen/26756/0000%22">acknowledgement</a> of an association between head trauma and chronic traumatic encephalopathy, a neurodegenerative disease <a href="https://www.abc.net.au/news/2023-04-26/danny-frawley-family-urges-afl-to-act-on-cte-concussion/102269648">found</a> in several deceased players. </p>
<p>The <a href="https://www.aihw.gov.au/reports/sports-injury/sports-injury-in-australia/contents/sports-injury-hospitalisations">latest data</a> show concussion can happen in nearly every sport, not just contact sports, with almost 3,100 hospitalisations for concussion caused by sports in 2020–21.</p>
<p>But not everyone responds the same way to concussion. At present, there are <a href="http://dx.doi.org/10.1136/bjsports-2017-097729">few reliable indicators</a> of who will suffer specific or long-term effects. We do know the number and severity of <a href="http://dx.doi.org/10.1136/bjsports-2017-097729">symptoms</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/23508730/">multiple concussions</a> are important. And we are developing understanding of how a person’s genes play a role. </p>
<h2>Traumatic brain injury</h2>
<p>Concussion is a form of traumatic brain injury that can result in <a href="https://theconversation.com/concussions-can-cause-disruptions-to-everyday-life-in-both-the-short-and-long-term-a-neurophysiologist-explains-what-to-watch-for-192390">neurological dysfunction</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/27889010/">including</a> migraine, cognitive deficit, confusion, slowed reaction times, personality changes, drowsiness and emotional changes. Some people also suffer long-term problems with memory, thinking and other symptoms, such as anxiety and mood disturbances. </p>
<p>After brain injury there is a cascade of events that impacts the health of neurons and affects the flow of chemical ions, such as calcium, in the brain. Mutations in genes that affect the transport of neuronal ions (atoms or molecules with a positive or negative electrical charge), termed <a href="https://www.frontiersin.org/articles/10.3389/fphar.2016.00121/full#:%7E:text=Ion%20channels%20are%20membrane%20proteins,or%20physical%20and%20chemical%20stimuli.">ion channel genes</a>, can also affect how the brain works. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1606923959370502145"}"></div></p>
<p>The strongest evidence of a connection between concussion response and ion channel gene function is from patients with a family history of a rare type of migraine (hemiplegic migraine, which causes the sufferer to experience severe migraine associated with motor impairment and muscle weakness) and <a href="https://rarediseases.info.nih.gov/diseases/10975/familial-hemiplegic-migraine">episodic ataxia</a> (which causes bouts of movement incoordination). </p>
<p>Specific types of these severe neurogenetic disorders are caused by mutations in the calcium channel gene <a href="https://pubmed.ncbi.nlm.nih.gov/8898206/">CACNA1A</a>. Patients with these mutations can be highly sensitive to head impacts. Some <a href="https://doi.org/10.1002/ana.1031">specific mutations</a> can see very minor head trauma lead to concussion, seizures, cerebral oedema (swelling), coma and <a href="https://onlinelibrary.wiley.com/doi/full/10.1016/j.pmrj.2017.07.081">sometimes death</a>. </p>
<p>Research has also shown 35% of patients with <a href="https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-021-01309-4#:%7E:text=Most%20ATP1A2%20mutations%20cause%20familial,disability%20%5B4%2C%2027%5D.">mutations</a> in a second hemiplegic migraine ion channel gene, ATP1A2 – which is linked to hemiplegic migraine, ataxia, epilepsy and other seizures and controls brain sodium and potassium levels, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7693486/">report</a> concussion symptoms following mild head trauma. </p>
<p>Focusing on all ion channel genes, our genomics lab (<a href="https://www.qut.edu.au/research/centre-for-genomics-and-personalised-health">Griffiths Centre for Genomics and Personalised Health</a>) recently studied 117 concussion-affected people. We found mutations in 21 ion channel genes, 14 of which could have an impact on concussion susceptibility or outcomes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/concussion-almost-half-of-people-still-show-signs-of-brain-injury-after-six-months-204702">Concussion: almost half of people still show signs of brain injury after six months</a>
</strong>
</em>
</p>
<hr>
<h2>Other types of genes</h2>
<p>Apart from a role for ion channel genes, there have been a number of additional genes linked by research to concussion. </p>
<p>One of the most studied is the <a href="https://www.nia.nih.gov/health/alzheimers-disease-genetics-fact-sheet">ApoE gene</a>, which is involved in transporting cholesterol in the body and has long been recognised as a risk factor for Alzheimer’s disease. Studies have indicated a variant of this gene (ApoE4) is linked with <a href="https://pubmed.ncbi.nlm.nih.gov/30848161/">poorer</a> and more <a href="https://pubmed.ncbi.nlm.nih.gov/34333069/">long-term concussion outcomes</a>. Those who carry this variant are also more likely to have significant <a href="https://scholars.mssm.edu/en/publications/association-of-apoe-genotypes-and-chronic-traumatic-encephalopath">signs</a> of brain degeneration after concussion. </p>
<p>Another genetic variation in the ApoE gene that makes it less productive has been <a href="https://pubmed.ncbi.nlm.nih.gov/18185033/">linked</a> to a higher likelihood of concussion.</p>
<p>Beyond ApoE, genes that help control a variety of brain functions have been <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910946/">suggested</a> as factors in concussion – including some <a href="https://pubmed.ncbi.nlm.nih.gov/28100103/">involved</a> in neuronal growth, dopamine receptors and, <a href="https://pubmed.ncbi.nlm.nih.gov/33017352/">most recently</a>, brain axon (nerve fibre) development. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/hit-your-head-while-playing-sport-heres-what-just-happened-to-your-brain-203038">Hit your head while playing sport? Here's what just happened to your brain</a>
</strong>
</em>
</p>
<hr>
<h2>A predisposition for injury</h2>
<p>Questions concerning the link between genetic predisposition to injury in sport are not new. Twenty years ago, the Australian Law Reform Commission <a href="https://www.alrc.gov.au/publication/essentially-yours-the-protection-of-human-genetic-information-in-australia-alrc-report-96/">referred</a> to research showing </p>
<blockquote>
<p>[…] a milder form of this condition [CTE or punch-drunk syndrome] could occur in players of rugby, soccer and other sports associated with repetitive blows to the head.</p>
</blockquote>
<p>In 2016, the Australian Institute of Sport (AIS) released a <a href="https://pubmed.ncbi.nlm.nih.gov/27899345/">position statement</a> on the ethics of genetic testing and research in sport. But the <a href="https://www.concussioninsport.gov.au/__data/assets/pdf_file/0006/1090680/concussion-and-brain-health-position-statement-2023.pdf">latest</a> AIS Concussion and Brain Health Position Statement does not mention the use of genetic information concerning concussion-related susceptibility.</p>
<p>Currently, there is available DNA diagnostic testing for the two ion channel genes already implicated in concussion, because this testing is used for the diagnosis of familial hemiplegic migraine and episodic ataxia. But genetic testing is not currently undertaken for concussion.</p>
<p>In Australia, it is difficult to find information on whether genetic testing occurs in elite sport. In the United Kingdom, genetic testing <a href="https://doi.org/10.5114/biolsport.2018.70747">does take place</a>, although it is not common. Athletes and support staff there are <a href="https://theconversation.com/genetic-testing-is-being-used-in-sport-but-what-are-the-consequences-88604">open to the idea</a> of genetic information being used to improve sport performance and reduce injury risk.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/uncharted-brain-decoding-dementia-a-three-part-series-to-read-and-listen-to-193162">Uncharted Brain: Decoding Dementia – a three-part series to read and listen to</a>
</strong>
</em>
</p>
<hr>
<h2>What’s next?</h2>
<p>It is vital there is more careful consideration of genetic factors involved in concussion development and response. Clarification of the role of ion channel gene mutations and other gene variants, along with information from additional biomarkers and imaging, will be important in developing better concussion management and treatment approaches. </p>
<p>Before introducing genetic testing, regulatory and governance frameworks would also need careful consideration. Wider ethical and legal implications will need to be fully examined including health privacy laws, privacy of genetic samples, anti-discrimination laws and employment-related laws, especially in professional sport. </p>
<p>With the growing awareness of concussion-related injury risks highlighted by the Senate inquiry, further research in Australia could also investigate attitudes toward the use of genetic testing and predisposition to injury risk in sport.</p><img src="https://counter.theconversation.com/content/204528/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lyn Griffiths has received migraine and concussion research funding from the Australian National Health and Medical Research Council, US Migraine Research Foundation, US Dept of Defence and Teva, and in addition receives research funding for a Defence Innovation Hub from Australian Defence and from VariantBio for her Norfolk Island genetics studies. She is a member of the Human Genetics Society of Australasia and Chair of the Board of Censors for Diagnostic Genomics.</span></em></p><p class="fine-print"><em><span>Annette Greenhow receives funding from the Government of Canada Social Sciences and Humanities Research Council and previously received funding from Australian Catholic University and the City of Gold Coast Ambassador Program. She is affiliated with the Australia and New Zealand Sports Law Association as a board member (views are her own). </span></em></p>The genetic evidence behind why some people suffer longer term concussion effects is growing. But what are the ethical considerations that flow from that knowledge when it comes to sport?Lyn Griffiths, Professor, Queensland University of TechnologyAnnette Greenhow, Assistant Professor, Faculty of Law, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2060842023-06-14T20:10:13Z2023-06-14T20:10:13ZFirst Nations women don’t always access health care after head injuries from family violence. Here’s why<figure><img src="https://images.theconversation.com/files/531828/original/file-20230614-21-zf11ko.jpg?ixlib=rb-1.1.0&rect=24%2C12%2C3989%2C2106&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/silhouette-woman-sitting-on-bed-beside-1439614217">Shutterstock</a></span></figcaption></figure><p><em>Please be advised this article contains details of family violence.</em></p>
<hr>
<p>Aboriginal and Torres Strait Islander women are <a href="https://www.mja.com.au/journal/2008/188/10/hospitalisation-head-injury-due-assault-among-indigenous-and-non-indigenous">69 times</a> more likely than non-Indigenous women to be hospitalised with head injuries due to assaults. </p>
<p>But some Aboriginal and Torres Strait Islander women <a href="https://www.tandfonline.com/doi/full/10.1080/14461242.2023.2173018">don’t access</a> health care and support services after head injuries from family violence. Our <a href="https://www.tandfonline.com/doi/full/10.1080/0312407X.2023.2210115?src=">research</a>, published this week, explored some of the reasons why – and how these barriers can be overcome. </p>
<p>We found fear of child removal, poverty, coercive control and low awareness of traumatic brain injury related to <a href="https://www.indigenousmhspc.gov.au/publications/dfv">family violence</a> can all impact on when and how Aboriginal and Torres Strait Islander women <a href="https://www.anrows.org.au/project/improving-family-violence-legal-and-support-services-for-indigenous-women/">access health care and support services</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-nations-women-are-69-times-more-likely-to-have-a-head-injury-after-being-assaulted-we-show-how-hard-it-is-to-get-help-194249">First Nations women are 69 times more likely to have a head injury after being assaulted. We show how hard it is to get help</a>
</strong>
</em>
</p>
<hr>
<h2>What is traumatic brain injury?</h2>
<p>Traumatic brain injury is <a href="https://www.archives-pmr.org/article/S0003-9993(10)00650-7/pdf">caused by</a> a blow, jolt or bump to the head. <a href="https://doi.org/10.1080/10926771.2019.1591562">Non-fatal strangulation</a> can also lead to brain injury as the brain is deprived of oxygen. </p>
<p>Traumatic brain injuries vary from mild to severe, and can cause a range of behavioural, emotional, physical and psychological symptoms, <a href="https://pubmed.ncbi.nlm.nih.gov/12924684/">including</a>:</p>
<ul>
<li>poor memory</li>
<li>dizziness</li>
<li>headaches</li>
<li>lack of concentration</li>
<li>slowness to process information or make decisions</li>
<li>emotional dysregulation, such as inability to control anger</li>
<li>anxiety and depression</li>
<li>lack of insight, where the person with the injury does not realise the effect of their injury.</li>
</ul>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1541936693799833600"}"></div></p>
<p>The <a href="https://synapse.org.au/understanding-brain-injury/effects-of-brain-injury/">experience of brain injury</a> is unique to each person.</p>
<p>The degree of recovery is largely determined by the nature and extent of the injury as well as the level of engagement in rehabilitation. For <a href="https://www.braininjuryaustralia.org.au/download-bias-report-on-australias-first-research-into-family-violence-and-brain-injury/">moderate to severe</a> traumatic brain injury, recovery is most rapid in the first six months after the injury. </p>
<p>Even mild traumatic brain injury can have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8773525/">long-term impacts</a> on wellbeing, parenting capacity, relationships and day-to-day living. </p>
<p>Recovery can be maximised by providing education about the short- and long-term management of symptoms as well as the involvement of family in the rehabilitation and recovery phase. </p>
<h2>Listening to First Nations women</h2>
<p>To find out why Aboriginal and Torres Strait Islander women don’t always <a href="https://www.tandfonline.com/doi/full/10.1080/14461242.2023.2173018">access services</a>, we completed interviews and focus discussion groups with 28 women and 90 service provider professionals in Queensland and the Northern Territory.</p>
<p>Our study focused on Aboriginal and Torres Strait Islander women, as their voices are often <a href="https://theconversation.com/she-was-the-most-important-person-to-us-r-rubuntjas-story-shows-society-is-still-failing-first-nations-women-180857">silenced</a> when it comes to women’s safety.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/she-was-the-most-important-person-to-us-r-rubuntjas-story-shows-society-is-still-failing-first-nations-women-180857">'She was the most important person to us' – R. Rubuntja's story shows society is still failing First Nations women</a>
</strong>
</em>
</p>
<hr>
<h2>Fear of child removal</h2>
<p>In results similar to those from family violence studies, women told us they avoided health care or minimised the amount of information they shared with health professionals to reduce the risk of contact with child protection authorities. One woman told us:</p>
<blockquote>
<p>We won’t report when there is domestic violence. If there is any words that come from the woman that [her] children were there, children are considered at risk and so they are taken. </p>
</blockquote>
<p>Some women told us their children had been removed following reporting and seeking support following family violence.</p>
<h2>Risks of further violence</h2>
<p>Sometimes women were prevented from accessing health care by manipulation and coercive control. This included partners preventing them accessing a working phone or transport. </p>
<p>One service provider said:</p>
<blockquote>
<p>A lot of users of violence I guess employ such a level of control and coercion that sometimes women are prevented from seeking medical treatment, or attempts to seek medical treatment, or disclose violence, including assaults to the head. It might actually make the situation worse. </p>
</blockquote>
<h2>Women prioritise competing demands</h2>
<p>Community-based service providers recognised the strength and resilience of women in continuing their roles caring for children and other family members after experiencing family violence.</p>
<p>Service providers told us their clients were often also managing financial and housing worries. One service provider told us:</p>
<blockquote>
<p>When a woman arrives here, the most important thing is rest, food, and finding that space to just sit with what’s happened, and then medical attention. I don’t always hear women prioritising medical attention in the first instance. I think that rest definitely, and even hunger, on a real, basic survival level. </p>
</blockquote>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
</strong>
</em>
</p>
<hr>
<h2>Awareness of brain injury</h2>
<p>Community members and leaders we spoke to had low levels of awareness, knowledge and recognition of the long-term damage violence can have on the brain. One community member said:</p>
<blockquote>
<p>We didn’t know about this brain injury. </p>
</blockquote>
<p>Another participant said:</p>
<blockquote>
<p>I didn’t go to the hospital. I had a bit of [a] headache, didn’t think it was serious enough to [go] and get checked, it [headache] went away. It happened many times. One time I black out, wasn’t aware of the lasting harm that can cause.</p>
</blockquote>
<h2>So what are the solutions?</h2>
<p>There are a range of opportunities to address several of these barriers. </p>
<p>First, service providers (including <a href="https://doi.org/10.1002/ajs4.200">within child protection systems</a>) need to ensure women receive compassionate care, referrals and links to support services for traumatic brain injury in a meaningful, timely and appropriate way.</p>
<p>There are <a href="https://www.familymatters.org.au/wp-content/uploads/2022/11/20221123-Family-Matters-Report-2022-1.pdf">strong calls</a> to have community-controlled organisations deliver child protection services – with many potential benefits to families and communities. </p>
<p>We also need to resource communities to design, implement and evaluate traumatic brain injury prevention and early intervention solutions. </p>
<p>Community-wide and school-based education were among some of the recommendations from community members to help people recognise the signs of traumatic brain injury and the importance of seeking help.</p>
<p>Other strategies to improve access to services include placing supports such as social workers outside of acute, hospital settings – for example, in <a href="https://www.tandfonline.com/doi/full/10.1080/26408066.2023.2202665?src=">GP clinics</a> and Aboriginal Community Controlled Health Services. </p>
<p>Finally, front-line staff and university students need high-quality training and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6645196/">education about traumatic brain injury and family violence</a>, how it presents in parental behaviour, case management and referral pathways. </p>
<p>Any practical solutions must be implemented through local partnerships with Aboriginal and Torres Strait Islander peoples to ensure the measures are community-led, culturally safe and provide an overall benefit, without doing further harm.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/new-research-reveals-harrowing-stories-of-murdered-indigenous-women-and-the-failure-of-police-to-act-205655">New research reveals harrowing stories of murdered Indigenous women and the failure of police to act</a>
</strong>
</em>
</p>
<hr>
<p><em>If this article raises issues for you or someone you know, contact <a href="https://1800respect.org.au/">1800 RESPECT</a> (1800 737 732) or <a href="https://www.13yarn.org.au/">13YARN</a> (13 92 76). In an emergency, call 000.</em></p>
<p><em>Jody Barney is a co-author on the journal paper on which this article is based. The authors thank the project team, advisory group and participants who shared their time and knowledge.</em></p><img src="https://counter.theconversation.com/content/206084/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Fitts receives funding from the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Jennifer Cullen receives funding from the Department of Social Services and the NDIS. She is the CEO of Synapse Australia.</span></em></p>Some First Nations women who sustain head injuries from family violence don’t access health care and support. We studied why and found one reason is a fear their children will be taken away.Michelle Fitts, ARC DECRA Fellow, Institute for Culture and Society, Western Sydney UniversityJennifer Cullen, Adjunct Associate Professor, College of Healthcare Sciences, James Cook UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047022023-05-02T14:59:59Z2023-05-02T14:59:59ZConcussion: almost half of people still show signs of brain injury after six months<figure><img src="https://images.theconversation.com/files/523828/original/file-20230502-1704-vb0nir.jpg?ixlib=rb-1.1.0&rect=7%2C7%2C4985%2C3735&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Our study found changes in the way the thalamus functioned in people who'd had concussion.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-rendered-medically-accurate-illustration-thalamus-1292650525">SciePro/ Shutterstock</a></span></figcaption></figure><p>Around <a href="https://brain-amn.org/global-incidence-of-tbi/#:%7E:text=In%20conclusion%2C%2069%20million%20people,suffer%20a%20severe%20TBI%20annually.">56 million people globally</a> suffer a concussion each year. It’s common for concussion to cause <a href="https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594">short-term symptoms</a> such as a headache, nausea, sensitivity to light and problems concentrating. </p>
<p>But many people also struggle with long-term symptoms – including fatigue, trouble sleeping and concentrating, and emotional distress. <a href="https://onlinelibrary.wiley.com/doi/10.1111/acem.13844">Previous research</a> found that clinicians estimated one in ten people might experience long-term symptoms after a concussion. </p>
<p>But our recent study estimates that post-concussive symptoms are far more common. Our study, published in <a href="https://academic.oup.com/brain/advance-article/doi/10.1093/brain/awad056/7051141">Brain</a>, found that almost half of people who suffered a concussion had not fully recovered six months after their injury. </p>
<p>To conduct our study, we analysed brain scans from over 100 patients who had recently experienced concussion from all across Europe. These brain scans were conducted using a technique called resting-state functional MRI (fMRI). </p>
<p>A resting-state fMRI measures brain activity when a person is at rest, which can be used to understand how different regions of the brain communicate. This allows us to understand if the brain is functioning as it should or if there are problems with a person’s brain connectivity.</p>
<p>A resting-state fMRI can also tell us more than a CT scan or MRI might. While these types of scans are often given to concussion patients, both only look for structural changes in the brain – such as inflammation or bruising. </p>
<p>Such changes often don’t occur in mild concussion cases soon after injury, which may lead clinicians to believe no brain damage has occurred. But a resting-state fMRI can show us more subtle changes in brain function – and may help us better predict who is more likely to develop long-term symptoms. </p>
<p>In our analyses, we specifically looked for changes in a region in the centre of the brain called the thalamus. This region is important in integrating sensory information and relaying it throughout the entire brain. </p>
<p>The thalamus is also thought to be <a href="https://link.springer.com/article/10.1007/s11065-020-09474-0/figures/2">very vulnerable</a> to the kind of external force that leads to concussion (such as a fall or blow to the head). </p>
<p>Our research found that concussion was associated with increased functional connectivity between the thalamus and the rest of the brain very shortly after injury, when compared to 76 healthy control subjects. </p>
<p>In other words, the thalamus was trying to communicate more as a result of the injury. This was despite routine MRI and CT imaging showing no structural changes in the brain.</p>
<figure class="align-center ">
<img alt="Two football players lie on the ground holding their heads." src="https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/523829/original/file-20230502-28-u2s167.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The thalamus may be particularly sensitive to the kind of forces that cause concussions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lubin-poland-june-05-2014-michal-197028332">Dziurek/ Shutterstock</a></span>
</figcaption>
</figure>
<p>While many of us would assume that more connectivity in the brain is a good thing, research looking at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6664441/">more severe head injuries</a> indicates that greater connectivity between brain regions might actually be a sign of the brain trying to compensate and offset damage across the brain.</p>
<p>We also found that almost half of people with concussion had not fully recovered six months after the injury. Our analysis showed that participants who had signs of greater thalamus connectivity in their brain very soon after injury were more likely to later develop post-concussive symptoms, such as fatigue and poor concentration.</p>
<h2>Concussion treatment</h2>
<p>Our research makes an important step in understanding concussion, showing that even a single brain injury can have clear consequences in some people. This damage may also not show up in the types of scans concussion patients are routinely given, suggesting it may be time to expand the types of imaging used. </p>
<p>We found that in people who experienced long-term symptoms, functional changes were still present in the brain 12 months after the injury. These effects were found in a sub-group who returned for scanning a year after their injury, and were not seen in patients without long-term symptoms. </p>
<p>Concussion is often viewed as a short-term event, but these findings suggest it can be a long-term disease, and some people may take longer to recover than others. </p>
<p>Our study also found that the long-term symptoms a person experiences may relate to different areas of the brain. We found that people who experienced long-term cognitive symptoms (such as concentration and memory problems) had increased connectivity from the thalamus to areas of the brain linked with noradrenaline – a chemical messenger in the brain. </p>
<p>Whereas people who experienced long-term emotional problems (such as depression or irritability) had greater connectivity to areas that produced a different chemical messenger, serotonin. </p>
<p>This not only shows us how concussion affects people differently, it may also give us targets we can use to develop drugs that alleviate concussion symptoms. </p>
<p>While concussion is considered a “mild” traumatic brain injury, our findings show it’s anything but – and can have long-term consequences for a large proportion of people. Although there’s still a lot we don’t know about concussion – including the effects that repetitive concussion may have on the brain – it’s promising to see this condition is being taken more seriously, especially in sports where it can be common. </p>
<p><a href="https://www.sportandrecreation.org.uk/policy/research-publications/concussion-guidelines">New UK guidelines</a> for grassroots sports like football and rugby now require players to sit out of play for at least 24 hours after a suspected concussion, which may help to prevent concussion and improve recovery after one.</p><img src="https://counter.theconversation.com/content/204702/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rebecca Woodrow receives funding from the Medical Research Council and the Pinsent Darwin Trust. </span></em></p><p class="fine-print"><em><span>David Menon receives research funding from the National Institute for Health Research, UK; UK Research and Innovation (UKRI); the Medical Research Council (UK); the Canadian Institute for Advanced Research (CIFAR); Addenbrooke's Charitable Trust; the Brain Research Trust (UK). He has consultancy or research collaboration agreements with NeuroTrauma Sciences LLC, Gryphon Inc, GlaxoSmithKline Ltd; Lantmannen AB; Pressure Neuro Ltd; Integra NeuroSciences Ltd; Cortirio Ltd; and Calico LLC.</span></em></p><p class="fine-print"><em><span>Emmanuel A Stamatakis receives funding from the Canadian Institute for Advanced Research and the Stephen Erskine Fellowship, Queens’ College, University of Cambridge.</span></em></p>Long-term symptoms of concussion can include trouble concentrating and emotional distress.Rebecca Woodrow, PhD Student in Clinical Neurosciences, University of CambridgeDavid Menon, Professor, Head of Division of Anaesthesia, University of CambridgeEmmanuel A Stamatakis, Lead, Cognition and Consciousness Imaging Group, Division of Anaesthesia, University of CambridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2030382023-04-26T23:44:20Z2023-04-26T23:44:20ZHit your head while playing sport? Here’s what just happened to your brain<figure><img src="https://images.theconversation.com/files/522897/original/file-20230426-28-n7he5i.jpg?ixlib=rb-1.1.0&rect=0%2C5%2C1917%2C1270&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/boys-playing-soccer-during-day-3413645/">Patrick Case/Pexels</a></span></figcaption></figure><p>It’s Friday night, your team is playing, and scores are nail-bitingly close. A player intercepts the ball, and bam! A player tackles his opponent to the ground. Trainers and doctors gather nervously while the commentators wait for confirmation: a concussion, mild traumatic brain injury, head knock, strike, tap, bump, blow … there are many terms for it.</p>
<p>How to prevent and treat such injuries is the subject to a <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Headtraumainsport">Senate inquiry</a>, with public hearings this week.</p>
<p>But what exactly are these injuries? What’s going on in the brain?</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/concussion-risks-arent-limited-to-the-afl-we-need-urgent-action-to-make-sure-our-kids-are-safe-too-155638">Concussion risks aren't limited to the AFL. We need urgent action to make sure our kids are safe, too</a>
</strong>
</em>
</p>
<hr>
<h2>What is concussion?</h2>
<p>Concussion is a form of traumatic brain injury (TBI). Concussion typically falls at the milder end of the spectrum, and so is often called mild TBI.</p>
<p>Concussions happen most often when the head directly hits against something. But it can also happen without head impact, when a blow to the body causes the head to move quickly. </p>
<p>The brain is a soft organ in a hard case, floating in a thin layer of <a href="https://medlineplus.gov/lab-tests/cerebrospinal-fluid-csf-analysis/">cerebrospinal fluid</a>. The brain can be damaged away from the site of impact for this reason, as it bounces with force within the skull.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1591444863698042883"}"></div></p>
<p>Concussions that happen during sport can be complex because the head often rotates as the person falls. This “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979340/">rotational acceleration</a>” can cause more damage to the brain. This is especially the case for cells in the long tracts of white matter responsible for relaying signals around the brain.</p>
<p>As well as causing initial damage to brain cells at the time of injury, concussion sets off a cascade of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4479139/">chemical and biological changes</a>. These occur within minutes and may last for days or even weeks after concussion. </p>
<p>Cell membranes become permeable (more leaky), causing an imbalance of brain chemicals inside and outside cells. Cellular functions shift into overdrive to try to restore balance, using more fuel in the form of glucose. At the same time, blood flow to the brain is often reduced, resulting in a mismatch between energy supply and demand. </p>
<p>The structural scaffolding of cells in the white matter may begin to weaken or break, preventing or reducing the ability of cells to communicate.</p>
<p>Sensing danger, cells from the <a href="https://pubmed.ncbi.nlm.nih.gov/28910616/">immune system</a> begin to migrate to the brain in an attempt to stem the damage, spouting chemical signals to recruit other inflammatory cells to the sites of injury. </p>
<p>These initial responses to concussion typically resolve over time, but the recovery period may be different for each person, and may persist even after symptoms go away.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/repeated-head-injury-may-cause-degenerative-brain-disease-for-people-who-play-sport-juniors-and-amateurs-included-196042">Repeated head injury may cause degenerative brain disease for people who play sport – juniors and amateurs included</a>
</strong>
</em>
</p>
<hr>
<h2>What are the symptoms?</h2>
<p>Concussion <a href="https://www.mayoclinic.org/diseases-conditions/concussion/symptoms-causes/syc-20355594">symptoms</a> can differ depending on the person and the circumstances of injury. </p>
<p>Some people have more obvious symptoms like loss of consciousness, vomiting and confusion; others may have headaches, problems with their vision, or thinking and concentration. Some people may have one symptom while others have many. Some people’s symptoms may be severe, and others may have only mild symptoms.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1649993694802485250"}"></div></p>
<p>So diagnosing and managing concussion can be difficult. Most people who have a concussion will find their symptoms subside within days or weeks. But around <a href="https://pubmed.ncbi.nlm.nih.gov/26918481/">20% of people</a> will have persistent symptoms beyond three months after their concussion. </p>
<p>Ongoing symptoms can make it harder to perform at work or school, to socialise with friends and to maintain relationships. Scientists don’t know why recoveries are different for different people. We have no way to <a href="https://bmjopen.bmj.com/content/11/5/e046460.info">predict</a> who will recover from concussion and who won’t.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/having-a-brain-injury-does-not-mean-youll-get-dementia-97254">Having a brain injury does not mean you'll get dementia</a>
</strong>
</em>
</p>
<hr>
<h2>How about repeat blows to the head?</h2>
<p>People who play contact sports are more likely to have multiple concussions over a playing career. Higher numbers of concussions tend to mean <a href="https://pubmed.ncbi.nlm.nih.gov/28387556/">worse symptoms and slower recovery</a> for subsequent concussions. </p>
<p>This indicates the brain doesn’t get used to concussions, and each concussion is likely to impart additional damage. </p>
<p>Emerging evidence suggests repeated concussions may lead to <a href="https://n.neurology.org/content/88/15/1400.short">ongoing changes</a> in people’s brain cell structure and function.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/32326805/">Inflammation</a> may persist inside and outside the brain. Inflammation may also <a href="https://pubmed.ncbi.nlm.nih.gov/30535946/">cause or contribute</a> to someone developing symptoms, and long-term brain functional and structural changes.</p>
<p>Prolonged symptoms and long-term brain changes may be worse in the long run for people who experience their concussions as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6595074/">young adults</a> compared to people who have concussions as older adults. </p>
<p>Scientists are also starting to find differences in <a href="https://pubmed.ncbi.nlm.nih.gov/30618335/">symptoms</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8596946/">brain alterations</a> in males and females. These could be related to newfound sex differences in the <a href="https://pubmed.ncbi.nlm.nih.gov/29104114/">scaffolding proteins</a> of male and female brains, making female brains more susceptible.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Female soccer players playing match" src="https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/522906/original/file-20230426-16-isrm2t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Concussion may be different for women, but we’re still learning how.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-athletes-playing-soccer-906073/">Noelle Otto/Pexels</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sports-concussions-affect-men-and-women-differently-female-athletes-need-more-attention-in-brain-research-160097">Sports concussions affect men and women differently. Female athletes need more attention in brain research</a>
</strong>
</em>
</p>
<hr>
<h2>We’ve known about this for a long time</h2>
<p>The long-term brain and behaviour changes resulting from repeated sports concussions have been reported since at least the <a href="https://www.bmj.com/content/1/3306/816">1920s</a>. Back then, it was seen in boxers and termed dementia pugilistica, or <a href="https://jamanetwork.com/journals/jama/article-abstract/260461">punch-drunk syndrome</a>. </p>
<p>We now call this condition <a href="https://www.sciencedirect.com/science/article/abs/pii/S1934148211005296">chronic traumatic encephalopathy</a> (CTE). People found to have CTE don’t always experience severe symptoms. Instead, symptoms tend to emerge or worsen later in life, even decades after injury or at the end of a playing career.</p>
<p>People also have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8166432/">varied symptoms</a> that can sometimes be hard to measure, like confusion, impaired judgement and aggression. This has made diagnosis difficult while people are alive. We can only confirm CTE after someone dies, by detecting altered structural proteins of the brain in <a href="https://link.springer.com/article/10.1007/s12024-023-00624-3">specific brain areas</a>. </p>
<p>There is still a lot to learn about CTE, including the exact processes that cause it, and why some people will develop it and others won’t.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-we-know-about-cte-the-brain-condition-that-affected-danny-frawley-145395">Here's what we know about CTE, the brain condition that affected Danny Frawley</a>
</strong>
</em>
</p>
<hr>
<h2>Concussion is common</h2>
<p>Concussion is a common injury almost <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7048626/">30%</a> of us will experience in our lifetime. </p>
<p>Although we have a lot still to learn, the current advice for people who experience concussion is to seek medical advice to help with initial management of symptoms and guide decisions on returning back to playing sports.</p>
<hr>
<p><em>For coaches, trainers, parents and others interested in learning more about how to manage concussion, resources are available from <a href="https://www.connectivity.org.au/">Connectivity Traumatic Brain Injury Australia</a>. These include its <a href="https://www.connectivity.org.au/concussion-short-course/">free concussion short courses</a> to help you understand, recognise and manage a concussion injury when it occurs.</em></p><img src="https://counter.theconversation.com/content/203038/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Hellewell receives funding from the Medical Research Futures Fund and the Bryant Stokes Neurological Research Foundation.</span></em></p>Young or old, men or women. All can be at risk of concussion while playing contact sport. Here’s what we know happens in the brain.Sarah Hellewell, Research Fellow, Faculty of Health Sciences, Curtin University, and The Perron Institute for Neurological and Translational Science, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1728282022-11-15T09:17:13Z2022-11-15T09:17:13ZSport-induced traumatic brain injury: families reveal the ‘hell’ of living with the condition<p><em>This article is part of the Insights Uncharted Brain series.</em></p>
<hr>
<p>Jill* looked drained as we sat down to speak about her late husband. It had been a long day. It was February 2020, and we had been conducting interviews at the <a href="https://concussionfoundation.org/">Concussion Legacy Foundation</a> family huddle.</p>
<p>Despite being tired, Jill, 47, was keen to be interviewed. She wanted to share what she had gone through and hoped her story might help others. We sat down in a quiet corner of the foyer of the Rosen Centre hotel in Orlando, Florida, and I listened to her speak for over 90 minutes.</p>
<hr>
<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/sport-induced-traumatic-brain-injury-families-re-live-the-hell-of-living-with-the-condition-172828&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p><em>You can listen to more articles from The Conversation, narrated by Noa, <a href="https://theconversation.com/us/topics/audio-narrated-99682">here</a>.</em></p>
<hr>
<p>She told me all about her husband, Michael, a larger-than-life character who was the “life and soul of the party”. She spoke about how he had played many sports and had experienced multiple diagnosed concussions playing American Football and lacrosse – but this never dimmed his enthusiasm for sports.</p>
<p>Jill described how his behaviour gradually changed. How he forgot simple tasks. How he became aggressive. How his behaviour had become so erratic, she didn’t feel they were welcome at social events anymore. She said:</p>
<blockquote>
<p>You’re just watching somebody you love disappear before your eyes and it’s hell.</p>
</blockquote>
<p>Then one day she was on the phone to her husband while he was at work and the call went quiet. Jill rushed to his office, only to find that he had taken his own life. </p>
<p>Jill was one of the <a href="https://nsuworks.nova.edu/tqr/vol26/iss11/10/">23 interviews</a> we conducted with family members over the three days our research team spent at the Concussion Legacy Foundation event. Our conversations provided an insight into what it was like living with a former athlete with
<a href="https://concussionfoundation.org/CTE-resources/what-is-CTE">chronic traumatic encephalopathy</a> (CTE), a neurodegenerative disease similar to Alzheimer’s that has been caused by repetitive head impacts in contexts like <a href="https://theconversation.com/concussion-horror-of-sports-related-brain-damage-is-only-now-emerging-54139">sport</a> and the military.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><strong><em>This story is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> and is working with academics from different backgrounds who have been engaged in projects to tackle societal and scientific challenges.</em></p>
<hr>
<p>The people we spoke to had been through so much. The confusion, hurt and despair of seeing the mind of someone they love gradually deteriorate seemed overwhelming. But we also saw some positive signs, such as how they wanted to share their stories to help others, and how there appeared to be a shared determination to change things for the better and to <a href="https://theconversation.com/football-and-dementia-heading-must-be-banned-until-the-age-of-18-150575">make sport safer</a> so other families wouldn’t have to go through what they’d experienced. </p>
<h2>Head injuries in sport</h2>
<p>Chronic traumatic brain injury associated with boxing has been known about for around 100 years. <a href="https://pubmed.ncbi.nlm.nih.gov/23314081/">In 1928</a>, Harrison Martland first described chronic traumatic encephalopathy in retired boxers. It was first referred to as “punch-drunk syndrome” or “dementia pugilistica” and sometimes develops in boxers as a result of long-term sub-clinical concussions (not detectable by the usual clinical tests). </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"949355389220466688"}"></div></p>
<p>In 2002, neuropathologist Bennet Omalu <a href="https://pubmed.ncbi.nlm.nih.gov/15987548/">examined</a> the brain of Mike Webster, a former National Football League (NFL) player who died from a heart attack after his physical and mental health had rapidly deteriorated. Subsequently, former NFL players <a href="https://www.nytimes.com/2013/08/30/sports/football/judge-announces-settlement-in-nfl-concussion-suit.html">sued the league</a>, claiming that they had received head trauma or injuries during their football careers, which caused them long-term neurological problems.</p>
<p>The VA-BU-CLF UNITE <a href="https://www.bu.edu/cte/our-research/brain-bank/">Brain Bank</a> at Boston University is the largest tissue repository in the world focused on traumatic brain injury (TBI). In a <a href="https://www.usnews.com/news/national-news/articles/2017-07-25/110-of-111-deceased-nfl-football-players-brains-had-cte-study-finds">2017 study</a> into the first 202 donated brains, high rates of CTE were found, with 177 diagnosed with CTE, including 110 of 111 from the <a href="https://jamanetwork.com/journals/jama/fullarticle/2645104">NFL players</a> (99%). The brain bank now has over <a href="https://concussionfoundation.org/news/press-release/new-brain-bank-report-marks-1000-brain-donation-milestone">1,000 brains</a> from donors as young as 14 who have been exposed to brain traumas, primarily from playing sport. Studying these brains is crucial, not only for preventing, diagnosing and treating CTE, but also understanding the long-term consequences of concussion and traumatic brain injury.</p>
<p><a href="https://www.bu.edu/articles/2019/cte-football/">Subsequent research</a> from Boston University’s CTE Center in 2019 found that every year of playing full tackle American football increases the risk of developing CTE by 30%. So for every 2.6 years of playing, the risk of developing CTE doubles. </p>
<p>But the problem is not isolated to American sports. Compared with most other sports, rugby union has a relatively <a href="https://pubmed.ncbi.nlm.nih.gov/25586912/">high injury rate</a>, including at school level in the UK where it is <a href="https://www.frontiersin.org/articles/10.3389/fspor.2022.784103/full">often a compulsory sport</a>. In addition, it has been reported that there is about one brain injury per match in <a href="https://www.dailymail.co.uk/sport/sportsnews/article-9342339/One-player-international-rugby-match-suffers-brain-injury-players-bulk-up.html">international rugby</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/rugby-concussions-and-duty-of-care-why-the-game-is-facing-scrutiny-161773">Rugby, concussions and duty of care: why the game is facing scrutiny</a>
</strong>
</em>
</p>
<hr>
<h2>Demise of England’s ‘lions’</h2>
<p>In football, concussion often results from accidental head impacts (like head-to-head collisions or collisions with the goalposts). But a growing number of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5264439/">studies</a> have shown that detrimental sub-concussive impacts (a bump, blow or jolt to the head that does not cause symptoms) may result from repeatedly heading the ball. And there have been an increasing number of high-profile examples in recent years who have been raising awareness of this issue.</p>
<p>In late 2020, three incidents shifted attitudes on the dangers of football. First, Norbert “Nobby” Stiles, a member of England’s 1966 Fifa World Cup winning team, died. Stiles had been <a href="https://www.theguardian.com/football/2020/oct/30/nobby-stiles-world-cup-winner-with-england-1966-manchester-united-dies">diagnosed with dementia</a> and the cause of this disease was linked to repeated heading of the ball in his career.</p>
<p>Then, it was announced that Sir Bobby Charlton, another World Cup winning hero, had also <a href="https://www.theguardian.com/football/2020/nov/01/sir-bobby-charlton-diagnosed-with-dementia-wife-lady-norma-confirms">been diagnosed</a> with dementia. He was the second member of his family to suffer with this disease as his brother, Jack (who played in the same winning team) had died earlier in the year after his own battle with dementia. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2w3-Gggg8-s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>Bobby Charlton was thus the fifth of the 11 starting players in the 1966 final to have been diagnosed with neurological diseases. Media reports have linked all of these cases to the repeated heading of footballs during their playing careers.</p>
<p>But the first case that drew attention to the link between football and traumatic brain injury was that of Jeff Astle. Following his death in 2002, the coroner’s verdict at the inquest into his death at the age of 59 <a href="https://www.theguardian.com/sport/blog/2021/mar/11/football-grapples-slowly-with-brain-injury-19-years-on-from-jeff-astle">recorded a verdict</a> of “death by industrial disease”, linked to heading heavy, often rain-sodden, leather footballs. Astle’s health had deteriorated – he had struggled with an eating disorder and was unable to recognise his children.</p>
<p>Astle’s daughter, <a href="https://twitter.com/DawnAstle9/status/1330293548214784002">Dawn</a>, has become a leading figure in the <a href="https://www.theguardian.com/football/2022/feb/02/dawn-astle-dedicated-pfa-dementia-department">campaign</a> to protect footballers. She presented evidence to the 2020 DCMS committee on concussion and brain injury in sport. Her submission to the committee included the following comment:</p>
<blockquote>
<p>My dad choked to death in front of me, my mum and my sisters. Please think about that for one minute. He choked to death because his brain had been destroyed. Destroyed because he was a footballer. I don’t want any other family to go through what my family went through, and continue to go through every day. Please don’t let my dad’s death and all the other footballers deaths be in vain. My dad was my hero and my best friend. His death will haunt me forever. </p>
</blockquote>
<h2>Families speak out</h2>
<p>In February 2020, our team of five researchers were invited by Chris Nowinski, the CEO of the Concussion Legacy Foundation, to Orlando. The CLF is an international non-profit organisation that aims to support athletes affected by head injury, and to assist patients and families by providing personalised help to those struggling with the outcomes of brain injury.</p>
<p>Our interviews were conducted at their “family huddle”, which was a support event for family members to allow them to share stories and connect with others who have had similar experiences. </p>
<p>We were given the opportunity to talk to family members, and build trust and rapport. This gave us a greater insight and understanding of their world. We conducted interviews with the partners, parents, siblings and the children of the deceased athletes.</p>
<p>Our research, <a href="https://nsuworks.nova.edu/tqr/vol26/iss11/10/">published</a> in The Qualitative Report, was presented as an ethnodrama (playscript) to best allow the stories of the family members to be heard. This also showed the distinct temporal phases that these family members went through, and by sharing these stories we hope this raises awareness of the powerful emotions they have experienced.</p>
<hr>
<figure class="align-right ">
<img alt="Uncharted Brain, podcast series" src="https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494827/original/file-20221111-22-1t5f3l.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>This article is accompanied by a podcast series called <a href="https://theconversation.com/uk/topics/uncharted-brain-decoding-dementia-128903">Uncharted Brain: Decoding Dementia</a> which examines new research unlocking clues to the ongoing mystery of how dementia works in the brain. Listen to the full series via <a href="https://podfollow.com/the-anthill/view">The Anthill podcast</a>.</em></p>
<hr>
<h2>Disbelief and confusion</h2>
<p>Many of the people we spoke to said the initial stage, when they started to see changes in the behaviour of their loved one, created very strong emotions because they couldn’t understand why this was happening. They had seen someone they loved decline in front of their eyes. Alice, 68, reflected on seeing this change in her husband: “He went from functioning perfectly, to struggling to remember or do anything he was so used to doing.” </p>
<p>People went on to recall specific instances when this behavioural decline became noticeable. For example, David told us this about his brother: “Once when he went to the airport to pick up my aunt. He proceeded to drive her around, and she finally said, ‘Where are we going?’” He replied that he didn’t know. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1551975393812520960"}"></div></p>
<p>There was evidence of a mounting feeling of hopelessness that declines in neurological functioning were causing. Another striking, distressing example was this story Sophie told about her husband:</p>
<blockquote>
<p>One weekend, I had 12 big black trash bags to go out to the garbage. And I told him when I got up and went to work on Monday morning, I said, ‘those are going out to the trash tomorrow’. I came home after work and he had unpacked every trash bag … I just sat there and cried … I’d worked a 12-hour day. I said, ‘why did you unpack all that trash?’ and he couldn’t tell me why. He just didn’t know.</p>
</blockquote>
<p>Others reinforced other emotions at seeing this happening to their loved one. Emily explained how she felt: “I do think at the start you are in this sense of disbelief because the person you love is doing these things that are out of character.” And Evelyn reflected on the sadness of seeing such changes:</p>
<blockquote>
<p>I was shocked, but also felt like the world had been turned upside down. We were so happy. I remember just sobbing.</p>
</blockquote>
<p>Researchers have previously highlighted the emotional consequences that family members experience when they witness the decline of their loved one. For example, <a href="https://nsuworks.nova.edu/tqr/vol24/iss1/1/">one 2019 study</a> involving interviews with 20 wives of either current or retired professional American football players, revealed their serious concerns about the cognitive, emotional and behavioural decline of these players. Some wives identified behavioural changes that included rage, reduced positive social interactions and various erratic behaviour, like starting risky business ventures. </p>
<p>As we also found, deterioration in cognitive functioning meant that those affected by traumatic brain injury were no longer able to carry out simple household tasks and often struggled with language problems. </p>
<h2>Anger, guilt and fear</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/12592763/">Another study</a>, which examined families who have experienced a severe traumatic brain injury outside of sport highlighted the difficulties caused by the uncertainty of the situation – both in terms of the progression of the illness and how to support and deal with the cognitive, physical and behavioural changes exhibited after the injury. </p>
<p>All of this presents huge challenges to families. Negotiating appropriate treatment is hard and the emotional and physical exhaustion of dealing with these difficulties just keeps mounting up for the people involved.</p>
<p>Our participants explained the toll it took on them as they saw first-hand the severe changes in behaviour as their loved one experienced further decline. For example, Katherine said she felt drained and responsible. “It’s hard because you don’t know what’s happening,” she said. “So you just blame yourself and think you are the reason. And that’s not good for your own wellbeing.” </p>
<p>Helen spoke about her intense feelings as her partner drank as a response to his condition:</p>
<blockquote>
<p>I was so angry at him for making the same choices over and over with drinking though. Like, “you’ve drank so much that you fell down the stairs in front of me at home, are you kidding me?” And it hurt, you know, and left a lot on my plate, so I was really, really, angry. And that didn’t help things. </p>
</blockquote>
<p>Changes in behaviour created further problems for family members, such as how their loved one was perceived in social situations. Elizabeth described one specific incident at a party:</p>
<blockquote>
<p>We went to a catered event, and he would take the top of the [burger] bun off, take the meat out to eat, put the bun back, and then go to the next one. And someone caught him and was like, “what is he doing?” Of course, we never got invited back to any of those people’s homes. No one wanted to have anything to do with him because they couldn’t understand him.</p>
</blockquote>
<p>Laura also spoke about the implications of a lack of understanding of this condition, highlighting how others would misinterpret her husband’s actions. This led to feelings of sadness as they became socially isolated from their friends. She said: “When we went to events, a lot of people thought he was an alcoholic, because he could have one cocktail and then he’d fall. They had no idea that the falling had nothing to do with that one drink that he had. And it became very sad because people didn’t want to have us around.”</p>
<p>Our participants also spoke of the burden as a result of effectively becoming their partner’s primary caregiver. Sophie spoke about the struggles she faced with supporting her husband with daily tasks. “I couldn’t physically handle him,” she said. “At that point he was unstable. He would shuffle, and fall, and he couldn’t get in and out of the shower. He was also incontinent, and I couldn’t handle him by myself. I felt so weak.”</p>
<p>Evelyn also spoke of these experiences, highlighting that the physical size of her partner caused significant strain. “The sheer problem with these guys was their physical size. As the disease progressed, he fell probably 10-15 times a day, and we’d have to figure out how to get him up. I was both physically and mentally exhausted,” Evelyn said.</p>
<p>Meanwhile, others spoke of the physical fear of danger they felt. Like Emily who told us:</p>
<blockquote>
<p>I did become scared of him. I hate to say that, but I did. He made me sign some papers and I had no idea what they were. He was just escalating and escalating, and he was standing over me and I just knew if I didn’t sign that paper, I was in physical danger. Which was an awful thought to have about your own husband that you love. </p>
</blockquote>
<h2>Moving forward</h2>
<p>Our interviews gave family members the chance to reflect on their time living with and caring for their loved one, and also, how they might approach the situation differently. Helen told us she wished she had taken more time for herself, and advised anybody going through a similar situation to “get into therapy, to help you process everything and to let you have an outlet”.</p>
<p>Katherine agreed, saying: “You’ve got to try and take some time for yourself. I remember I took a trip with a girlfriend once and I was scared to death the whole time I was gone, but I went, and we had a wonderful time, and I’m so glad I did it. You know, trying to keep some semblance of normalcy in your life for yourself, for your own good. Try to keep yourself healthy, eat healthily, work out. Keep yourself well because there really was nothing, I could do for him except be present. I couldn’t make him well.”</p>
<p>Other family members reflected on the dangers of certain sports. For example, Alice highlighted how her awareness had increased, giving her the knowledge and understanding to allow her to come to terms with her husband’s situation. She realised there were “significant pathologies” that he had no control over that affected his decision-making.</p>
<blockquote>
<p>His brain was still functioning, and he was still able to make decisions, just the wrong parts of the brain were directing his decisions. That totally makes sense now, so that’s been a huge relief, that he wasn’t just an asshole in his own right, he really just couldn’t control it.</p>
</blockquote>
<p>While our data contained accounts full of sadness, participants also reflected on different ways they were moving forwards in a positive way after experiencing the death of a loved one. Laura detailed the benefits of attending the huddle and being with people who had been through similar struggles: “Everyone here is in the same boat. It may not have looked exactly the same for us, but we don’t have to explain for once. And just the support I’ve got from the people here has been great.”</p>
<p>Others talked about how the support helped the grieving process and inspired them to get involved and help other families. For example, Evelyn spoke of the need to make changes at a junior sport level: “I’m just so concerned this horrible disease is hitting younger and younger people, yet no one knows about it … giving people the information to be able to make the correct decision is super important.” </p>
<p>The final word goes to Elizabeth, who had become involved in the support work of the CLF, and spoke of her new found purpose to help others. She said it helped make her loss “bearable” because “millions” might benefit and “hopefully not have to experience the kind of tragedy that affected our family”.</p>
<blockquote>
<p>I feel like part of the reason this happened is for me to be part of raising more awareness and be a part of this movement towards new culture change. I can help families navigate … the difficult waters of dealing with this. And so, I feel like it speaks to sort of a calling … I have in life or part of my purpose.</p>
</blockquote>
<h2>Consequences</h2>
<p>What is clear to us after concluding this research project is that greater recognition of the challenges faced by both those living with diseases of the brain, such as CTE, and their carers is needed.</p>
<p>We heard about the devastating losses and tragedies. But we were also privileged to highlight more positive stories that showed how people were able to move forwards and help others to create a constructive change in sport so others won’t have to suffer.</p>
<p>It also illustrates how neurodegenerative disease resulting from head trauma as a consequence of impact sports has far reaching effects – not only the athletes, but also those around them. This represents a growing public health concern and societal problem. </p>
<p>It shows that greater recognition of the challenges faced by both those living with diseases of the brain, such as CTE, and their carers, is needed.</p>
<p>We hope their stories will stimulate discussion and be used to support people who might be going through similar experiences. Our findings might be used to help practitioners, sporting governing bodies and charities such as the CLF, to understand more fully these negative emotional responses and, in turn, consider strategies that might be developed to support people. In turn, these organisations must also act to address the causes of head injuries to make sports safer.</p>
<p><em>All names in this article have been changed to protect the anonymity of those involved.</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/climate-scientists-concept-of-net-zero-is-a-dangerous-trap-157368?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Climate scientists: concept of net zero is a dangerous trap
</a></em></p></li>
<li><p><em><a href="https://theconversation.com/sexual-exploitation-by-un-peacekeepers-in-drc-fatherless-children-speak-for-first-time-about-the-pain-of-being-abandoned-188248?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Sexual exploitation by UN peacekeepers in DRC: fatherless children speak for first time about the pain of being abandoned
</a></em></p></li>
<li><p><em><a href="https://theconversation.com/the-public-cost-of-private-schools-rising-fees-and-luxury-facilities-raise-questions-about-charitable-status-182060?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">The public cost of private schools: rising fees and luxury facilities raise questions about charitable status
</a></em></p></li>
</ul>
<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/172828/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Matthew Smith is affiliated with CLF-UK and has a role as research lead for Patient and Family Services. The aim of this role is to develop research that helps understand the experiences, and support patients and family members. </span></em></p><p class="fine-print"><em><span>Adam John White works for the Concussion Legacy Foundation. He receives funding from the EU Erasmus programme. </span></em></p><p class="fine-print"><em><span>Keith Parry is affiliated with the Concussion Legacy Foundation. </span></em></p>Researchers spoke to families of athletes who had suffered from traumatic brain injuries during their sporting careers.Matthew Smith, Senior Lecturer in Sport and Exercise Psychology, University of WinchesterAdam John White, Lecturer, Oxford Brookes UniversityKeith Parry, Head Of Department in Department of Sport & Event Management, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1923902022-11-10T13:43:24Z2022-11-10T13:43:24ZConcussions can cause disruptions to everyday life in both the short and long term – a neurophysiologist explains what to watch for<figure><img src="https://images.theconversation.com/files/494518/original/file-20221109-16873-evqs5d.jpg?ixlib=rb-1.1.0&rect=400%2C16%2C5166%2C3638&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sleep plays a critically important role in the recovery process in the days following a concussion.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/skiing-accident-royalty-free-image/164528977?phrase=concussion&adppopup=true">nicolamargaret/E+ via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://www.cnn.com/2022/10/19/sport/nfl-tua-tagovailoa-concussion-spt-intl">repeat concussions</a> suffered by Miami Dolphins quarterback Tua Tagovailoa less than a week apart in September 2022 have brought the seriousness of traumatic brain injury back into the public eye and <a href="https://www.washingtonpost.com/health/2022/09/30/tua-concussion-protocol-nfl/">triggered scrutiny</a> of the NFL’s concussion protocols. And the upcoming World Cup soccer competition, which begins Nov. 20, 2022, will likely include highly visible head injuries.</em></p>
<p><em>The Conversation asked David Howell, <a href="https://profiles.ucdenver.edu/display/15074432">director</a> of the <a href="https://medschool.cuanschutz.edu/orthopedics/research/labs/howell-concussion-lab/our-research">Colorado Concussion Research Laboratory</a> at the University of Colorado School of Medicine, to explain the latest science behind concussions and why a recently injured brain is more vulnerable to repeat injury. Howell’s work focuses on the many different areas of concussion-related dysfunction and recovery, including <a href="https://doi.org/10.3390/s20216297">movement deficits</a>, <a href="https://doi.org/10.1097/jsm.0000000000000803">sleep problems</a> and <a href="https://doi.org/10.1177/03635465211069372">rehabilitation</a>.</em></p>
<h2>How widespread are concussions?</h2>
<p>The word concussion can evoke a variety of different images for different people. While concussions are most visible during high-profile sporting events, they can also occur on the playground, during the junior varsity football team practice or on the ski slope. The effects can be just as severe for children and teens as for high-profile athletes.</p>
<p>Concussion effects range from mild to severe, from short term to long term, and can affect many different facets of life. A concussion is defined as a traumatic brain injury caused by an impact to the head, resulting in an alteration of brain function. </p>
<p>A concussion often leads to disruptions to everyday life – whether it be a job, academics, sports, physical activity or sleep. Given how unique people’s brains are and how differently they may respond to the injury, concussion recognition, diagnosis and treatment remain challenging for patients and clinicians alike. </p>
<h2>What happens to the brain during a concussion?</h2>
<p>There is a complex set of events that occur within the brain during and after a concussion occurs. </p>
<p>As a result of the trauma to the brain, brain cells – or neurons – stop functioning as they typically do when healthy. Generally there is not one specific area of the brain that is affected by a concussion. Instead, the injury can affect a widespread set of brain regions, not necessarily at the impact point. Thus, each person may experience a unique set of symptoms or functional problems following the injury. </p>
<p>One main problem that arises following a concussion is an <a href="https://doi.org/10.1016/j.csm.2020.08.001">energy crisis</a> of sorts. This occurs when the brain requires a large volume of energy, in the form of glucose delivered by blood flow to the brain, to restore the injured processes. The body also may have trouble delivering blood to the brain because of a brain blood flow disruption <a href="https://doi.org/10.3389/fneur.2018.00196">caused by the injury</a>, at the very time the brain needs extra energy to restore the injured areas. This mismatch can produce a variety of different symptoms people experience following a concussion.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/7Lfc7aZfd0Y?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Research suggests that a concussion can alter the brain’s wiring.</span></figcaption>
</figure>
<h2>What signs should you look for if you suspect a concussion?</h2>
<p>Concussions produce a wide range of signs and symptoms, such as problems with walking and balance, dizziness, mood changes, disruptions to sleep and more. </p>
<p>Some of the main signs that health care providers look for following an impact to the head or body include unsteadiness of gait, loss of consciousness, seizures or other concussion symptoms like headache, cognitive impairment or problems with vision or balance.</p>
<p>It is critical that if a concussion is suspected, individuals cease playing their sport or activity. A simple mantra of “<a href="https://sportscotland.org.uk/media/3382/concussionreport2018.pdf">If in doubt, sit them out</a>” should always be applied, regardless of the setting. </p>
<h2>Why is the injured brain more vulnerable to repeat injury?</h2>
<p>Miami Dolphins quarterback Tua Tagovailoa, who was <a href="https://www.cnn.com/2022/10/19/sport/nfl-tua-tagovailoa-concussion-spt-intl">carted off the field</a> in late September 2022 after his second head injury in less than a week, serves as an example of how vulnerable the brain can be to additional trauma following an initial concussion.</p>
<p>Research shows that the rate of second concussions is highest in the immediate <a href="https://doi.org/10.1136/bjsports-2019-100579">days following an initial concussion</a>. In addition, recent studies have found that athletes who continue to play following a concussion <a href="https://doi.org/10.1177/0363546518757984">experience longer recovery times</a> and <a href="https://doi.org/10.1007/s40279-022-01668-1">more severe symptoms</a>. </p>
<p>While athletes of all ages may want to continue competing after a concussion, relying on a person with an injured brain to determine whether their brain is healthy enough to continue playing is flawed logic. Qualified health care professionals should always make these sorts of decisions for an athlete, rather than someone with a vested interest such as the athletes themselves or their coaches.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Football players stand in a circle looking at a teammate stretched on the ground." src="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/494481/original/file-20221109-11066-izy6xc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Teammates gather around Miami Dolphins quarterback Tua Tagovailoa after an injury during the first half of an NFL game on Sept. 29, 2022.</span>
<span class="attribution"><a class="source" href="https://www.apimages.com/metadata/Index/Dolphins-Bengals-Football/2fc554f4223f4e0c9234f61e9f7e62da/1/0">AP Photo/Emilee Chinn/</a></span>
</figcaption>
</figure>
<p>Given the energy crisis described above that occurs following a head injury, the brain simply cannot handle the added and cumulative stress of two injuries occurring in short succession. A second insult to the brain is often simply too much for the brain to handle, and the brain will preserve its most basic functions, such as breathing, above all else. </p>
<p>This is why it is imperative that athletes who experience a concussion be removed from the field of play and allowed to recover fully before returning to unrestricted sport participation. This often involves <a href="https://doi.org/10.1136/bjsports-2017-097699">a stepwise reintegration approach</a>, which allows for a gradual and safe reintroduction into physical activity at first, and an appropriately safe return to play under medical care.</p>
<h2>You’ve had a concussion – now what?</h2>
<p>The first step following a concussion is to stop playing sports and to rest for a day or two. Sleep is <a href="https://doi.org/10.1089/neu.2021.0295">critically important</a> in the days following a concussion. </p>
<p>A myth that continues to persist is that a person should be woken up every hour following a concussion. This is simply not supported by science. In fact, poor sleep after a concussion has been widely documented as being a <a href="https://doi.org/10.1097/jsm.0000000000000803">predictor of poor outcomes</a>, including <a href="https://doi.org/10.1177/0009922816681603">longer recovery times</a> and more severe anxiety, depression or <a href="https://doi.org/10.1089/neu.2018.6257">cognitive symptoms</a>. Waking someone up every hour applies to <a href="https://doi.org/10.1093/bja/aem128">more severe brain injuries</a> that would be ruled out by a health care provider during diagnosis.</p>
<p>In addition, <a href="https://doi.org/10.1136/bjsports-2018-100338">recent guidelines</a> and <a href="https://doi.org/10.1542/peds.2014-0966">past research</a> suggest that complete physical and cognitive rest, which is <a href="https://doi.org/10.1097/wco.0000000000000611">sometimes called cocoon therapy</a>, can actually be <a href="https://doi.org/10.3389/fneur.2019.00362">harmful to recovery</a>. </p>
<p>Therefore, it is important to keep a balanced approach in mind. Following a day or two of physical rest, people with a concussion should begin resuming <a href="https://doi.org/10.1016/j.jpeds.2020.07.049">light physical and cognitive activity</a> that does not provoke or exacerbate ongoing symptoms. </p>
<p>When a person begins to feel better following a concussion, they should gradually add in higher intensity and greater amounts and duration of exercise, dictated by whether their symptoms are not significantly provoked. Recent studies have focused on the value of an individualized aerobic exercise program in the week following a concussion. Past work suggests that performing aerobic exercise at a heart rate just below the level at which symptoms are exacerbated is <a href="https://doi.org/10.1016/s2352-4642(21)00267-4">safe and effective for recovery</a>.</p>
<p>It is important to note that the effects of a concussion may also result in secondary conditions, such as anxiety or depression due to the biological, social or psychological effects of the injury. A recent study showed that adolescents who sustained a concussion have a <a href="https://doi.org/10.1001/jamanetworkopen.2022.1235">higher risk of mental health issues</a> compared to those with an orthopedic injury.</p><img src="https://counter.theconversation.com/content/192390/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Howell has received research support from the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute of Neurological Disorders And Stroke, the National Institute of Arthritis and Musculoskeletal and Skin Diseases, 59th Medical Wing Department of the Air Force, MINDSOURCE Brain Injury Network, the Tai Foundation, and the Colorado Clinical and Translational Sciences Institute and he serves on the Scientific/Medical Advisory Board/owns shares for Synaptek, LLC.</span></em></p>While high-profile concussions in the NFL have brought renewed attention to the gravity of head injuries, they can also occur on the playground or during junior varsity practices – with lasting effects.David Howell, Assistant Professor of Orthopedics,, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1942492022-11-10T04:09:03Z2022-11-10T04:09:03ZFirst Nations women are 69 times more likely to have a head injury after being assaulted. We show how hard it is to get help<figure><img src="https://images.theconversation.com/files/494551/original/file-20221110-17-4yfpkn.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C664&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-sitting-on-ground-arm-holding-461451844">Shutterstock</a></span></figcaption></figure><p><em>First Nations people, please be advised that the following article mentions family violence and assault.</em></p>
<hr>
<p>Aboriginal and Torres Strait Islander women are <a href="https://www.mja.com.au/journal/2008/188/10/hospitalisation-head-injury-due-assault-among-indigenous-and-non-indigenous">69 times more likely</a> than non-First Nations women to go to hospital with a head injury because of an assault.</p>
<p>But not all First Nations women get the support they need.</p>
<p><a href="https://www.mdpi.com/1660-4601/19/22/14744">Our new study</a> shows how health and support services working in remote areas are not equipped with the tools to identify the potential of a head injury for women who experience violence.</p>
<p>Not only are service workers not asking women about a potential traumatic brain injury, there’s a lack of referral options, and often no diagnosis, limiting women’s access to services and supports for recovery.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/four-corners-how-many-more-reveals-the-nations-crisis-of-indigenous-women-missing-and-murdered-193216">Four Corners' 'How many more?' reveals the nation's crisis of Indigenous women missing and murdered</a>
</strong>
</em>
</p>
<hr>
<h2>What is traumatic brain injury?</h2>
<p>Head injuries after an assault range from cuts and bruises to the type that can cause longer-term damage, known as traumatic brain injury. </p>
<p>Traumatic brain injury <a href="https://www.sciencedirect.com/science/article/pii/S0003999310006507">is defined as</a> damage to, or alteration of, brain function due to a blow or force to the head. Non-fatal strangulation can also lead to <a href="https://www.biausa.org/public-affairs/media/strangulation-domestic-violence-and-brain-injury-an-introduction-to-a-complex-topic">brain injury</a> as the brain is deprived of oxygen.</p>
<p>Such injury can have short-term (acute) effects or cumulative effects (over months or years). Changes vary from person to person but can include memory loss, difficulty with motivation, impaired awareness, sensory problems, mood changes and anxiety. </p>
<p>Some types of traumatic brain injury are also a <a href="https://theconversation.com/having-a-brain-injury-does-not-mean-youll-get-dementia-97254">risk factor</a> for early onset dementia.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
</strong>
</em>
</p>
<hr>
<h2>We’re talking about family violence</h2>
<p>Our work tries to understand the needs and priorities of First Nations women who have experienced a traumatic brain injury due to family violence.</p>
<p>Timely and culturally safe care, and support, following such brain injury is vital. But not all First Nations women <a href="https://theconversation.com/aboriginal-australians-want-care-after-brain-injury-but-it-must-consider-their-cultural-needs-115128">get access</a> to it.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1542331369497366533"}"></div></p>
<p>So, in early 2022, we spoke to 38 professionals from various sectors – including health, crisis accommodation and support, disability, family violence, and legal services – working across remote areas of the Northern Territory.</p>
<p>The data offers insights into the barriers that can prevent people asking First Nations women about possible brain injury, and women’s access to health care afterwards.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/aboriginal-australians-want-care-after-brain-injury-but-it-must-consider-their-cultural-needs-115128">Aboriginal Australians want care after brain injury. But it must consider their cultural needs</a>
</strong>
</em>
</p>
<hr>
<h2>Often, there’s no follow-up</h2>
<p>Participants told us that while the more severe cases were evacuated from a remote community to a hospital, less-severe cases were not always followed up.</p>
<p>One participant told us: </p>
<blockquote>
<p>Women are often not evac-ed out following a head injury, if it’s assessed to not be an urgent thing, so might not necessarily be getting CT scans.</p>
</blockquote>
<p>CT scans can help inform diagnosis, treatment and support. </p>
<p>Service providers were also often unaware of follow-up pathways to identify and connect women with the right supports, should they have ongoing symptoms.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1541936693799833600"}"></div></p>
<h2>A fly-in, fly out workforce</h2>
<p>Participants told us that high workforce turnover and <a href="https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-017-0229-9">fly-in, fly-out health services</a> in remote regions could also affect identification of traumatic brain injury.</p>
<p>They told us short-term staff can lack knowledge and familiarity of working in remote communities, and in building community relationships.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fly-in-fly-out-heath-care-fails-remote-aboriginal-communities-7948">Fly-in, fly-out heath care fails remote Aboriginal communities</a>
</strong>
</em>
</p>
<hr>
<h2>Lack of referral, diagnosis, training</h2>
<p>Not all women were referred to neuropsychologists (health professionals who might assess symptoms), which led to gaps in medical reports and formalised assessments. One participant told us: </p>
<blockquote>
<p>I don’t know any who actually have a confirmed diagnosis.</p>
</blockquote>
<p>This has implications for how women are managed and the supports they receive.</p>
<p>None of the staff we interviewed had completed training about traumatic brain injury. One told us:</p>
<blockquote>
<p>We get ADD [attention-deficit disorder] workshops, we get domestic and family violence workshops, disability support workshops, but nothing around brain injury.</p>
</blockquote>
<p>Other than some legal services, service providers did not ask specific questions of women who had experience violence and assaults about possible traumatic brain injury. </p>
<p>One participant said: </p>
<blockquote>
<p>We’ll screen for domestic violence, but we don’t screen for specific injuries.</p>
</blockquote>
<h2>What can we do about it?</h2>
<p>As our research shows, First Nations women with traumatic brain injury need better access to support and services, which is critical for their long-term recovery. </p>
<p>Here’s how we support frontline staff:</p>
<ul>
<li><p>design and roll out education about traumatic brain injury to develop staff knowledge and confidence. This education needs to be tailored to the type of frontline staff (remote area nurses will clearly need different education to housing staff), be designed with First Nations input and be culturally appropriate</p></li>
<li><p>ask women about the possibility of traumatic brain injury as part of existing family violence and health assessments</p></li>
<li><p>ask culturally appropriate questions that are not meant to diagnose traumatic brain injury, but help to identify cognitive impairment and complex disability </p></li>
<li><p>explore different ways of delivering rehabilitation for mild traumatic brain injury, and whether telehealth might be appropriate under some circumstances.</p></li>
</ul>
<p>Giving a voice to First Nations women living with traumatic brain injury is also crucial to providing the necessary supports during their rehabilitation and recovery.</p>
<hr>
<p><em>If this article raises issues for you or someone you know, contact <a href="https://1800respect.org.au">1800 RESPECT</a> (1800 737 732) or <a href="https://www.13yarn.org.au/">13YARN</a> (13 92 76). In an emergency, call 000.</em></p>
<hr>
<p><em>Dr Gail Kingston (Townsville Hospital and Health Service) and Elaine Wills (Western Sydney University and Menzies School of Health Research) are co-authors of the journal paper on which this article is based. The authors would like to thank members of the project advisory group and all participants who shared their time and knowledge.</em></p><img src="https://counter.theconversation.com/content/194249/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Fitts receives funding from the Australian Research Council and the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>Jennifer Cullen receives funding from the Department of Social Services and the NDIS. She is the CEO of Synapse Australia.</span></em></p><p class="fine-print"><em><span>Karen Soldatic receives funding from the Australian Research Council and the National Health and Medical Research Council. </span></em></p>Health and service workers are not asking women about a potential traumatic brain injury, there’s a lack of referral options, and often no diagnosis.Michelle Fitts, ARC DECRA Fellow, Institute for Culture and Society, Western Sydney UniversityJennifer Cullen, Adjunct Associate Professor, College of Healthcare Sciences, James Cook UniversityKaren Soldatic, Professor, School of Social Sciences & Institute Principle Fellow, Institute for Culture and Society, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1898992022-09-25T10:00:46Z2022-09-25T10:00:46ZConcussion is more than sports injuries: Who’s at risk and how Canadian researchers are seeking better diagnostics and treatments<figure><img src="https://images.theconversation.com/files/486306/original/file-20220923-16-bx9qew.jpg?ixlib=rb-1.1.0&rect=11%2C170%2C7171%2C4867&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Concussion doesn’t just happen in sports or only in teens and young adults; it affects people of all ages and backgrounds.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Concussions are becoming more common again as people return to regular activities following COVID-19 lockdowns and restrictions, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8873554/">when concussion rates declined</a>. Each year, <a href="https://doi.org/10.1097/htr.0000000000000503">about one per cent of Canadians sustain concussions</a>, amounting to some 400,000 concussions in Canada alone. Worldwide, that number grows to over 40 million annually.</p>
<p>Concussion is a critical public health concern. Up to 30 per cent of <a href="https://doi.org/10.1016/j.jpeds.2022.03.039">children</a> and <a href="https://doi.org/10.1089/neu.2016.4677">adults</a> will have persistent problems after concussion that lower their quality of life and hinder their return to work, sport, school and other activities. </p>
<h2>Prevention, diagnosis and treatment</h2>
<p>Important questions remain about concussion prevention, diagnosis and treatment. In 2019, <a href="https://www.ourcommons.ca/DocumentViewer/en/42-1/HESA/report-24/">the Parliamentary Subcommittee on Sports-Related Concussions in Canada</a> called for the creation of a national expert group and a coordinated national research program. </p>
<p>In response, the <a href="https://ccn-rcc.ca/en/">Canadian Concussion Network/Réseau Canadien des Commotions</a> (CCN-RCC) was launched in 2020 to establish a Canadian research agenda spanning all causes of concussions, as well as to support knowledge translation to bring research evidence into clinical practice where it can improve patient care.</p>
<p>We are all members of the CCN-RCC Executive Committee or Advisory Council. We include a neuropsychologist, neurosurgeon and neuroscientist. We are all active researchers whose interests reflect the broader concussion research community in Canada, and two of us are also clinicians. Some recent advances in Canadian concussion research — including who is affected by concussions — may come as a surprise to readers.</p>
<h2>Who gets concussions?</h2>
<figure class="align-center ">
<img alt="Person sitting on the ground" src="https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484996/original/file-20220916-18-i7e2p1.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Homelessness is linked to increased risk of concussion.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Concussion doesn’t just happen in sport or only in teens and young adults; it affects people of all ages and backgrounds. Young children and older adults often sustain concussions in falls. Recently, <a href="https://doi.org/10.1080/02699052.2019.1658129">intimate partner violence</a> has been identified as a common cause of concussion, with traumatic brain injury (TBI) occurring in up to 80 per cent of survivors, mostly women. </p>
<p>Concussion and TBI are also extremely common among individuals experiencing <a href="https://doi.org/10.1089/neu.2017.5076">homelessness</a>. About 35 per cent of study subjects experiencing homelessness reported a head injury with TBI symptoms. </p>
<p>More research on concussion is needed among systemically disadvantaged groups, especially Indigenous people, who <a href="https://theconversation.com/indigenous-women-suffer-greatest-risk-of-injury-87164">experience higher rates of injury</a>. Building on Canada’s many advances in sport-related concussion research, we now need to ask how we can better prevent, diagnose and treat <em>all</em> concussions.</p>
<h2>Preventing sport-related concussion</h2>
<p>The best concussion is one that never happens. Prevention of sport-related concussion is a key focus of Canadian concussion research. When body checking was shown to increase the risk of concussion in <a href="http://doi.org/10.1001/jama.2010.755">youth hockey</a>, policy changes disallowing body checking for players under 13 resulted in a <a href="http://dx.doi.org/10.1136/bjsports-2019-101092">reduction of over 4,500 concussions annually</a>. </p>
<p>Recently, one of the largest <a href="http://dx.doi.org/10.1136/bjsports-2019-101011">studies of mouthguards</a> to date found they likely prevent concussions in youth ice hockey. This evidence will interest parents concerned about their children playing contact sports and may encourage sporting organizations to institute policies requiring mouthguards. </p>
<figure class="align-center ">
<img alt="Field hockey team in a huddle" src="https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484994/original/file-20220916-16-p2bwez.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Contact sports are a common cause of concussions among adolescents.</span>
<span class="attribution"><span class="source">(Pixabay)</span></span>
</figcaption>
</figure>
<p>More broadly, <a href="https://www.parachute.ca/en/">Parachute</a>, the largest charitable organization in Canada devoted to injury prevention, is leading the <a href="https://www.parachutecanada.org/en/professional-resource/concussion-collection/concussion-harmonization-project/">Concussion Harmonization Project</a>, supported by the Public Health Agency of Canada and in collaboration with Sport Canada. The project’s goal is to establish consistent concussion guidelines and protocols in more than 50 sports in Canada based on the <a href="https://parachute.ca/en/professional-resource/concussion-collection/canadian-guideline-on-concussion-in-sport/">Canadian Guideline on Concussion in Sport</a>, which is grounded in scientific evidence.</p>
<h2>Diagnosing concussion with biomarkers</h2>
<p>Concussions are not usually visible using standard neuroimaging diagnostic tools, such as CT scans. The diagnosis of concussion relies largely on the observation of signs such as unconsciousness or vomiting and the reporting of symptoms such as headache, dizziness or “brain fog.”</p>
<p>However, injuries are not always directly observed, and people cannot or do not always report their symptoms accurately. Canadian researchers are studying <a href="https://doi.org/10.3389/fneur.2021.787480">biomarkers of concussion</a> — using biofluids like saliva or blood, or advanced neuroimaging — that may eventually be used on the sideline or in the emergency room to identify concussion more accurately. </p>
<figure class="align-center ">
<img alt="Medical imaging of human brain" src="https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484997/original/file-20220916-14-45ags5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advanced neuroimaging may identify biomarkers of concussion.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>In collaboration with Statistics Canada, <a href="https://alz.confex.com/alz/2022/meetingapp.cgi/Paper/64762">age-based reference intervals</a> for blood-based biomarkers are being developed that could be applied in concussion diagnosis across the lifespan.</p>
<h2>Predicting concussion outcomes</h2>
<p>When a child sustains a concussion, parents want to know their prognosis and how long their recovery will take. Although most children recover in two to four weeks, some show more prolonged symptoms. </p>
<p>Researchers have developed a <a href="http://doi.org/10.1001/jama.2016.1203">clinical prediction rule</a> for children and adolescents that can be used to tell families the likelihood of persistent symptoms. Physicians can reassure parents of children who are at low risk and target help for those with higher risk, based on easily accessible information.</p>
<h2>Promoting recovery from concussion</h2>
<figure class="align-center ">
<img alt="Woman with gray hair on the floor, holding her head after a fall" src="https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/484993/original/file-20220916-22-p2bwez.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Falls are a leading cause of concussion in older adults.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>People with concussion used to be told to rest in a dark room until their symptoms stopped. However, we now know resting more than one or two days can slow recovery. </p>
<p>Instead, <a href="http://dx.doi.org/10.1136/bjsports-2021-105030">early reintroduction of activity</a>, and even low-intensity exercise, can promote recovery and reduce persistent symptoms. </p>
<p>Researchers are also developing effective, targeted treatments for persistent symptoms. For instance, <a href="http://doi.org/10.1097/HTR.0000000000000504">cognitive behavioral therapy for insomnia</a> is very effective at reducing the sleep problems that often happen after concussion.</p>
<h2>Concussion Awareness Week</h2>
<p>In 2013, high school rugby player <a href="http://doi.org/10.1017/cjn.2019.14">Rowan Stringer tragically died</a> after incurring multiple concussions in rugby over six days. Rowan’s death prompted the passage of <a href="https://www.ontario.ca/page/rowans-law-concussion-safety">Rowan’s Law in Ontario</a>, the only concussion legislation to date in Canada (by comparison, all 50 U.S. states have passed concussion legislation). </p>
<p>Rowan’s death was an impetus for the creation of the <a href="https://www.ourcommons.ca/DocumentViewer/en/42-1/HESA/report-24/">Parliamentary Subcommittee on Sports-Related Concussions in Canada</a>. One of the Subcommittee’s recommendations was to establish a pan-Canadian Concussion Awareness Week, which began in 2021 and takes place this year from Sept. 25 to Oct. 1.</p>
<p>We wanted to make Canadians aware that Canadian researchers are conducting innovative research to reduce concussion, improve its identification and diagnosis, and find better treatments. Promoting the translation of that research into more evidence-informed practices and policies, nationally and internationally, is a crucial next step.</p><img src="https://counter.theconversation.com/content/189899/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Keith Yeates receives funding from Canadian Institutes of Health Research, and has had recent funding from Brain Canada and Alberta Health Services. He also receives an editorial stipend from the American Psychological Association.</span></em></p><p class="fine-print"><em><span>Cheryl Wellington receives funding from Canadian Institutes of Health Research, Weston Brain Institute, Department of Defence, National Institutes of Health. </span></em></p><p class="fine-print"><em><span>Charles H. Tator does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Canadian researchers are exploring unanswered questions about concussion: How to diagnose it accurately and quickly, how to predict outcomes and promote recovery, and how to prevent it altogether.Keith Yeates, Professor and Head, Psychology, and Ronald and Irene Ward Chair in Pediatric Brain Injury, University of CalgaryCharles H. Tator, Program Director, Canadian Concussion Centre, and Professor of Neurosurgery, University of TorontoCheryl Wellington, Professor and Vice Chair Research, Department of Pathology and Laboratory Medicine, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1847402022-07-21T12:25:29Z2022-07-21T12:25:29ZSilent, subtle and unseen: How seizures happen and why they’re hard to diagnose<figure><img src="https://images.theconversation.com/files/470665/original/file-20220623-64215-3tfegq.jpg?ixlib=rb-1.1.0&rect=7%2C22%2C5104%2C3380&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approximately 10% of people will experience at least one seizure during their lifetime.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/brain-and-brain-waves-in-epilepsy-royalty-free-illustration/973895626?adppopup=true">Kateryna Kon/Science Photo Library via Getty Images</a></span></figcaption></figure><p>The dramatic and incapacitating nature of seizures is reflected in the word itself, which derives from the Greek “to take hold” – like an invisible force suddenly grasping someone and controlling their body. This sense of an unknown force has driven many superstitions and misrepresentations of seizures throughout history.</p>
<p>Over the past century, the public’s understanding of seizures has been gleaned mostly from depictions in movies and television, which are often as disturbing as they are inaccurate. While these dramatic representations intensify visual storytelling, they frequently perpetuate stigma and <a href="https://doi.org/10.1111/j.1528-1157.1999.tb00836.x">understate the complexity of seizures</a>. </p>
<p>The truth is, seizures are far more varied than what you see in popular culture. Instead, they are often subtle, silent and unseen.</p>
<p><a href="https://som.ucdenver.edu/Profiles/Faculty/iframeProfile/30305">As a neurologist</a> who focuses on the comprehensive care of people who experience seizures, I subspecialize in the treatment of those with epilepsy. That includes identifying and improving gaps in epilepsy care. Research shows there are many.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/PG12JfJJW9U?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Epilepsy is a complex condition, but it is also treatable.</span></figcaption>
</figure>
<h2>Why seizures occur</h2>
<p>A seizure is caused by sudden uncontrolled <a href="https://www.cureepilepsy.org/for-patients/understanding/basics/what-is-seizure/?">electrical activity from a group of neurons</a>. This hyperactivity overwhelms the brain’s normal tendency to suppress such abnormal activity on both a cellular and network level. </p>
<p>Not all seizures are indicative of epilepsy. An otherwise normal brain may experience seizures during alcohol withdrawal. Seizure-like events may also occur with an acute decrease in blood flow, which can cause fainting. </p>
<p>Seizures associated with epilepsy, on the other hand, are <a href="https://www.epilepsydiagnosis.org/">unprovoked and often very difficult to predict</a>. A broad spectrum of underlying abnormalities can all lead to the development of epileptic seizures, including brain tumors, infections, strokes, traumatic brain injury, autoimmune conditions, developmental abnormalities and genetic predispositions.</p>
<h2>Seizures are not uncommon</h2>
<p>Approximately 1 in 10 people <a href="https://doi.org/10.1212/WNL.40.8.1163">will experience a seizure</a> during their lifetime. But only those with a risk of recurrent unprovoked seizures are <a href="https://doi.org/10.1111/epi.13670">considered to have epilepsy</a>, which represents about <a href="https://doi.org/10.1111/J.1528-1157.1993.TB02586.X">1 in 26 people</a></p>
<p>Because of the wide variety of symptoms, substantial <a href="https://doi.org/10.1007/s11910-021-01161-8">delays to diagnosis and treatment</a> can happen. When unrecognized and untreated, seizures worsen over time and lead to <a href="https://doi.org/10.1016/j.yebeh.2015.10.020">decreased quality of life</a>, <a href="https://doi.org/10.1111/epi.16707">cognitive impairments</a>, <a href="https://doi.org/10.1111/j.1528-1157.1995.tb01660.x">injuries, including motor vehicle accidents</a>, and <a href="https://doi.org/10.1093/brain/awt117">sometimes death</a>. </p>
<p>The irony is, much of the suffering is unnecessary. Most people with epilepsy <a href="https://doi.org/10.1111/j.1528-1167.2009.02481.x">can be seizure-free</a> through the use of an inexpensive medication.</p>
<h2>Focal seizures</h2>
<p>Regardless of the cause, <a href="https://doi.org/10.1111/j.1528-1167.2009.02481.x">focal seizures</a> are the most common type found in adults. This seizure type arises from hyperactivation of a confined brain region. For instance, a seizure arising from the left motor cortex of the brain may result in shaking of the right arm. A seizure arising from the visual cortex may cause a person to see flashes of light or other strange visual phenomena. </p>
<p>The most common brain region for focal seizures to arise is one of the temporal lobes, of which there are two – one on either side of the brain. These lobes serve many functions and are involved in vocal, auditory and visual processing, as well as emotions and memory. This is why seizures arising from these areas can lead to a variety of unusual symptoms.</p>
<p>Frequently, focal temporal lobe seizures are relatively subtle, particularly to witnesses. Sometimes they are comprised of purely unusual internal sensations such as sudden intense fear, a sudden sense of déjà vu or possibly a strong odor. Until a seizure spreads to involve more areas of the brain, it may not cause loss of consciousness or convulsions.</p>
<p>Because untreated seizures become more frequent and severe over time, it is not uncommon for epilepsy to begin with these relatively subtle focal seizures, then worsen as the seizures begin to involve more brain tissue, and eventually progress to convulsions.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/W_uXaXwVQ4c?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">People affected by epilepsy discuss the myths surrounding the condition.</span></figcaption>
</figure>
<h2>Delays in diagnosis</h2>
<p>A patient of mine described having strange symptoms for over a decade – symptoms he had not discussed before with me or anyone else. He described recurrent, sudden-onset euphoric sensations, which progressed to an inability to speak for one to two minutes. A bystander would think he was just staring into space. Over the years, these sensations increased in frequency. They eventually became more severe and led to loss of consciousness. </p>
<p>After the patient began an anti-seizure medication regimen, the sensations went away, and he reported improvements in both memory and cognition. Fortunately, he did not experience physical injury, or worse, before his evaluation. But many people are not so lucky.</p>
<p>Recent studies have confirmed that <a href="https://doi.org/10.1002/epi4.12443">delays in diagnosis are common</a> among people who have epilepsy. Undoubtedly, this is because the early subtle and unusual symptoms are not well recognized by patients, families or medical professionals. </p>
<h2>A revealing study</h2>
<p><a href="http://www.humanepilepsyproject.org/">The Human Epilepsy Project</a> is a large, multinational prospective study that followed nearly 500 people with newly treated focal epilepsy for five years. I was among the researchers who analyzed the study’s data, and we found a striking diagnostic delay among many participants. Many of them experienced seizures for <a href="https://doi.org/10.1111/epi.16707">several months or even several years before diagnosis</a>. </p>
<p>From those first seizures to the diagnosis, half the participants experienced injuries; 5% had car accidents attributable to seizures. Extrapolating this data to the general population suggests that every year in the U.S., over 1,800 motor vehicle accidents are due to <a href="https://doi.org/10.1111/epi.16707">undiagnosed subtle focal seizures</a>. With a timely diagnosis, these accidents are potentially preventable.</p>
<p>However, even those evaluated for seizures don’t always receive the correct diagnosis or treatment. Nearly two-thirds of those participating in the Human Epilepsy Project sought an initial seizure evaluation in an emergency department. About 90% were there only after their first convulsive seizure – that is, after the seizure spread and now involved the full brain. </p>
<p>But leading up to that first convulsive seizure, nearly half of participants had been experiencing nonmotor focal seizures, which went largely unrecognized. For that reason, many people who <a href="https://doi.org/10.1111/acem.14114">could have been diagnosed with epilepsy</a> and started on treatment were not. </p>
<p>As it stands now, about 200,000 U.S. adults <a href="https://doi.org/10.1111/j.1528-1167.2008.01443.x">seek evaluation at a hospital’s emergency department</a> for a first lifetime seizure every year. Often, they are diagnosed with epilepsy at that time or shortly thereafter. Poor recognition of subtle seizures bears significant consequences for individuals, communities and the health care system. Improving our understanding of the diverse ways seizures arise and affect lives will help us close the gap and lessen the consequences.</p><img src="https://counter.theconversation.com/content/184740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jacob Pellinen receives funding in the form of grants from the University of Colorado Department of Neurology, NIH/NCATS Colorado CTSA Grant Number UL1 TR002535, and from the American Epilepsy Society.</span></em></p>Because some seizures are relatively subtle, they can go unrecognized, leading to a delay in diagnosis.Jacob Pellinen, Assistant Professor of Neurology, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1809452022-05-05T12:42:27Z2022-05-05T12:42:27ZYou’ve likely heard of the brain’s gray matter – here’s why the white matter is important too<figure><img src="https://images.theconversation.com/files/458358/original/file-20220415-24-rq7g23.jpg?ixlib=rb-1.1.0&rect=0%2C14%2C5000%2C3712&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The brain's neural network, which includes both gray and white matter.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/brain-neural-network-royalty-free-illustration/460711949?adppopup=true">Pasieka/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Who has not contemplated how a memory is formed, a sentence generated, a sunset appreciated, a creative act performed or a heinous crime committed?</p>
<p>The human brain is a three-pound organ that remains largely an enigma. But most people have heard of the brain’s <a href="https://pubmed.ncbi.nlm.nih.gov/31990494/">gray matter</a>, which is needed for cognitive functions such as learning, remembering and reasoning. </p>
<p>More specifically, gray matter refers to regions throughout the brain where nerve cells – <a href="https://www.ninds.nih.gov/health-information/patient-caregiver-education/brain-basics-life-and-death-neuron#">known as neurons</a> – are concentrated. The region considered most important for cognition is <a href="https://www.ninds.nih.gov/health-information/patient-caregiver-education/brain-basics-know-your-brain#The%20Cerebral%20Cortex">the cerebral cortex</a>, a thin layer of gray matter on the brain’s surface. </p>
<p>But the other half of the brain – <a href="https://www.medicalnewstoday.com/articles/318966#Viewing-white-matter">the white matter</a> – is often overlooked. White matter lies below the cortex and also deeper in the brain. Wherever it is found, white matter connects neurons within the gray matter to each other.</p>
<p>I am a <a href="https://medschool.cuanschutz.edu/alzheimer/about/directory/faculty/christopher-filley">professor of neurology and psychiatry</a> and the director of the behavioral neurology section at the University of Colorado Medical School. My work involves the evaluation, treatment and investigation of older adults with dementia and younger people with traumatic brain injury.</p>
<p>Finding out how these disorders affect the brain has motivated many years of my study. I believe that understanding white matter is perhaps a key to understanding these disorders. But so far, researchers have generally not given white matter the attention it deserves.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An illustration showing how neurons in the human brain connect to each other via the axons, which are surrounded by the myelin sheath." src="https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=492&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=492&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461121/original/file-20220503-50169-zdtzie.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=492&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The approximately 100 billion neurons in the human brain are connected to each other by axons, many of which are surrounded by the myelin sheath. These axons, together with their myelin, make up the white matter, which helps facilitate communication between neurons throughout the brain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/neuron-nerve-cell-body-in-orange-is-represented-with-its-news-photo/179798658?adppopup=true">BSIP/Universal Images Group via Getty Images</a></span>
</figcaption>
</figure>
<h2>Figuring out the white matter</h2>
<p>This lack of recognition largely stems from the difficulty in studying white matter. Because it’s located below the surface of the brain, even the most high-tech imaging can’t easily resolve its details. But recent findings, made possible by advancements in brain imaging and autopsy examinations, are beginning to show researchers how critical white matter is.</p>
<p>White matter is comprised of many <a href="https://qbi.uq.edu.au/brain/brain-anatomy/axons-cable-transmission-neurons">billions of axons</a>, which are like long cables that carry electrical signals. Think of them as elongated tails that act as extensions of the neurons. The axons connect neurons to each other at junctions called synapses. That is where communication between neurons takes place. </p>
<p>Axons come together in bundles, or tracts, that course throughout the brain. Placed end to end, their combined length in a single human brain is approximately 85,000 miles. Many axons are <a href="https://www.brainfacts.org/brain-anatomy-and-function/anatomy/2015/myelin">insulated with myelin</a>, a layer of mostly fat that speeds up electrical signaling, or communication, between neurons by up to 100 times. </p>
<p>This increased speed is crucial for <a href="https://www.nbia.ca/brain-structure-function/">all brain functions</a> and is partly why Homo sapiens have unique mental capacities. While there’s no doubt <a href="https://www.quantamagazine.org/how-humans-evolved-supersize-brains-20151110/#">our large brains</a> are due to evolution’s addition of neurons over eons, there has been an even greater <a href="https://doi.org/10.1073/pnas.090504197">increase in white matter</a> over evolutionary time. </p>
<p>This little-known fact has profound implications. The increased volume of white matter – mainly from the myelin sheaths that surround axons – enhances the efficiency of neurons in the gray matter to optimize brain function.</p>
<p>Imagine a nation of cities that are all functioning independently, but not linked to other cities by roads, wires, the internet or any other connections. This scenario would be analogous to the brain without white matter. Higher functions like language and memory are organized into networks in which gray matter regions are connected by white matter tracts. The more extensive and efficient those connections, the better the brain works.</p>
<h2>White matter and Alzheimer’s</h2>
<p>Given its essential role in the connections between brain cells, <a href="https://doi.org/10.1196/annals.1444.017">damaged white matter</a> can disturb any aspect of cognitive or emotional function. White matter pathology is present in many brain disorders and can be severe enough <a href="https://doi.org/10.1196/annals.1444.017">to cause dementia</a>. Damage to myelin is common in these disorders, and when the disease or injury is more severe, axons can also be damaged.</p>
<p>More than 30 years ago, my colleagues and I described this syndrome as <a href="https://medschool.cuanschutz.edu/docs/librariesprovider61/publications/wmd-paper-nnbn-1988_web.pdf?sfvrsn=435286ba_2">white matter dementia</a>. In this condition, the dysfunctional white matter is no longer adequately performing as a connector, meaning that the gray matter cannot act together in a seamless and synchronous manner. The brain, in essence, has been disconnected from itself. </p>
<p>Equally important is the possibility that white matter dysfunction plays a role in many diseases currently thought to originate in gray matter. Some of these diseases stubbornly defy understanding. For example, I suspect white matter damage may be critical in the early phases of Alzheimer’s disease and traumatic brain injury. </p>
<p>Alzheimer’s is the <a href="https://www.webmd.com/alzheimers/guide/alzheimers-dementia">most common type of dementia in older individuals</a>. It can impair cognitive function and rob people of their very identity. No cure or effective treatment exists. Ever since <a href="https://doi.org/10.1002/ca.980080612">Alois Alzheimer’s 1907 observations</a> of gray matter proteins – called amyloid and tau – neuroscientists have believed the buildup of these proteins <a href="https://doi.org/10.1056/NEJMra0909142">is the central problem</a> behind Alzheimer’s. Yet many drugs that remove these proteins <a href="https://doi.org/10.1080/21507740.2021.1941402">do not stop</a> <a href="https://theconversation.com/the-fda-approved-a-new-drug-to-treat-alzheimers-but-medicare-wont-always-pay-for-it-a-doctor-explains-what-researchers-know-about-biogens-aduhelm-179177">the patients’ cognitive decline</a>. </p>
<p><a href="https://doi.org/10.1093/braincomms/fcaa132">Recent findings increasingly suggest</a> that white matter damage – preceding the accumulation of those proteins – <a href="https://doi.org/10.1093/braincomms/fcaa132">may be the true culprit</a>. As brains age, they often experience gradual loss of blood flow from the narrowing of vessels that convey blood from the heart. Lower blood flow heavily impacts white matter. </p>
<p>Remarkably, there is even evidence that inherited forms of Alzheimer’s also feature <a href="https://doi.org/10.1002/ana.24647">early white matter abnormalities</a>. That means therapies aimed at maintaining blood flow to white matter may prove more effective than attempting to dislodge proteins. One simple treatment likely to help is <a href="https://doi.org/10.1001/jama.2019.10551">controlling high blood pressure</a>, as this can reduce the severity of white matter abnormalities. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/lNdRtTTbLDM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">From Loma Linda University Health: New discoveries to help the millions with traumatic brain injuries.</span></figcaption>
</figure>
<h2>White matter and traumatic brain injury</h2>
<p>Patients with traumatic brain injury, particularly those with moderate or severe injuries, can have lifelong disability. One of the most ominous outcomes of TBI is <a href="https://doi.org/10.1097/NEN.0b013e3181a9d503">chronic traumatic encephalopathy</a>, a brain disease believed to cause progressive and irreversible dementia. In TBI patients, the accumulation of tau protein in gray matter is evident. </p>
<p>Researchers have long recognized that white matter damage is common in people who have sustained a TBI. <a href="https://doi.org/10.1212/WNL.0000000000013012">Observations from the brains</a> of those with repetitive traumatic brain injuries – football players and military veterans have been frequently studied – have shown that white matter damage is prominent, and may precede the appearance of tangled proteins in the gray matter. </p>
<p>Among scientists, there is a burgeoning excitement over the <a href="https://doi.org/10.1007/s11357-021-00461-8">new interest in white matter</a>. Researchers are now beginning to acknowledge that the traditional focus on the study of gray matter has not produced the results they hoped. Learning more about the half of the brain known as white matter may help us in the years ahead to find the answers needed to alleviate the suffering of millions. </p>
<p>[<em>Get more science, health and technology news.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=science&source=inline-science-fascinating">Sign up for The Conversation’s weekly science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/180945/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher M. Filley receives funding from the Marcus Institute for Brain Health at the University of Colorado, and the U.S. Department of Defense, In the past he has received funding from the U.S. National Institutes of Health.</span></em></p>Long overlooked by scientists, white matter may provide clues to some of the brain’s greatest mysteries.Christopher M. Filley, Professor of Neurology and Psychiatry, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1765412022-02-10T19:10:44Z2022-02-10T19:10:44ZThe risk of concussion lurks at the Super Bowl – and in all other sports<figure><img src="https://images.theconversation.com/files/444890/original/file-20220207-66930-1gnpd0b.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4878%2C3232&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Over the past two decades, researchers have gained a great deal of insight into the risks surrounding concussions – some of which has led to sweeping policy changes.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/tom-brady-of-the-tampa-bay-buccaneers-calls-the-play-during-news-photo/1300905188?adppopup=true">Kevin C. Cox/Getty Images Sports via Getty Images</a></span></figcaption></figure><p>An estimated 90 million to 100 million Americans will tune in to watch the <a href="https://www.latimes.com/sports/story/2022-02-09/super-bowl-2022-start-time-teams-location-channel-halftime-show">Super Bowl this Sunday</a>. Unlikely to be mentioned during the festivities is this sobering but significant side note: Athletes participating in collision sports are among those <a href="https://doi.org/10.1007/s40279-021-01428-7">at highest risk for concussion</a>. </p>
<p>That risk is not limited to professional football. Researchers estimate that <a href="https://doi.org/10.1097/00001199-200609000-00001">4 million sports and recreation-related concussions</a> occur in the U.S. every year, across all sports and all levels of play and in both games and practices. They happen to athletes and kids playing basketball and soccer and weekend warriors who bicycle and ski. But thousands of concussions also result from car accidents, slips and trips or other blows to the head.</p>
<p>I’m the director of the <a href="https://concussion.umich.edu/">University of Michigan Concussion Center</a>, and <a href="https://concussion.umich.edu/leadership/steven-broglio/">I have been researching</a> brain injuries <a href="https://scholar.google.com/citations?user=DE-SIlkAAAAJ&hl=en">for nearly a quarter-century</a>. Across the globe, hundreds more researchers like me have dedicated their careers to understanding concussions and traumatic brain injuries – and, most critically, how to prevent and treat them. While tremendous progress has been made, much more remains to be done.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/xvjK-4NXRsM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">How dangerous are concussions? The answer is complicated.</span></figcaption>
</figure>
<h2>The backstory</h2>
<p>When I began my career, concussions were broadly viewed as “getting your bell rung.” It was not uncommon for an athlete who had been knocked out to be sent back into a game within 20 minutes of injury. </p>
<p>The devastating results of repeat concussions without appropriate treatment led to the adoption of <a href="https://www.shapeamerica.org/standards/guidelines/Concussion/state-policy.aspx">sweeping legislation</a> that specifically addressed youth sports concussions. </p>
<p>That legislation, enacted between 2009 and 2014, is law in all 50 states. Although it varies from state to state, youth athletes now receive annual education on concussions. Those suspected of having a concussion must be removed from play, and concussed athletes can’t play their sport until cleared by a medical professional. </p>
<p>In 2005, researchers discovered the first case of <a href="https://doi.org/10.1227/01.neu.0000163407.92769.ed">chronic traumatic encephalopathy</a> in a former professional football athlete. The degenerative brain disease is characterized by protein deposits that have been linked to concussions and repeated head impacts.</p>
<p>This monumental finding occurred concurrently with U.S. military involvement in Iraq and Afghanistan. For both conflicts, traumatic brain injury <a href="https://doi.org/10.1176/appi.neuropsych.16050100">became the signature injury</a> of returning veterans, and the U.S. government increased funding to study short- and long-term effects of concussion. </p>
<p>In addition, sports organizations <a href="https://www.cbssports.com/nfl/news/for-first-time-ever-nfl-admits-theres-a-link-between-cte-and-football/">reversed their prior stance</a> and acknowledged the link between concussions and long-term injury. They began supporting policies that embraced evidence-based rule changes to reduce concussion risk. </p>
<figure class="align-center ">
<img alt="Children play soccer on a grassy field." src="https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/445305/original/file-20220209-21-bmsr84.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Even young athletes can sustain concussions when playing contact sports like football, basketball and soccer.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/boys-playing-football-royalty-free-image/BC0459-001?adppopup=true">Bob Thomas/The Image Bank via Getty Images</a></span>
</figcaption>
</figure>
<h2>A golden age of concussion research</h2>
<p>Those events laid the foundation for a new generation of scientists to explore precise ways to diagnose concussions, develop novel treatment options and understand who’s most at risk for negative long-term outcomes. </p>
<p>That includes three transformative studies that are currently underway in the U.S.: <a href="https://tracktbi.ucsf.edu/transforming-research-and-clinical-knowledge-tbi">TRACK-TBI</a>, which is evaluating 3,000 patients across traumatic brain injury spectrum; <a href="https://www.childrenshospital.org/nfl-long-study/findings">NFL-LONG</a>, which tracks former NFL players; and the <a href="http://www.careconsortium.net/">CARE Consortium</a>, which has enrolled more than 55,000 military service academy members and collegiate athletes to better understand the short- and long-term effects of concussion. </p>
<p>The CARE Consortium, which I co-lead, has produced more than 100 peer-reviewed papers that have contributed to overall improvements in concussion diagnosis and management. Notably, we reported that recovery from a concussion <a href="https://doi.org/10.1007/s40279-021-01541-7">may take up to one month</a>. We also discovered that male and female athletes return to post-concussion play <a href="https://doi.org/10.1136/bjsports-2020-103316">at the same rate</a> and <a href="https://doi.org/10.1001/jamanetworkopen.2019.19771">identified blood-based markers</a> that may eventually serve as the gold standard for concussion diagnosis. </p>
<p>My colleagues and I are now starting follow-up evaluations of the CARE Consortium participants to better understand the long-term effects of injury. Those findings, along with work from other studies, will inform researchers on the risk of long-term neurodegeneration and shine a light on ways to intervene with medications and therapies. </p>
<h2>The future</h2>
<p>Concussion research is flourishing. Since the first modern case of chronic traumatic encephalopathy was identified 17 years ago, more than 13,000 papers have been published in the medical literature. Although researchers have much more to learn, the advances in concussion care over the past 20 years are clearly significant. Concussed athletes are now <a href="https://doi.org/10.1136/bjsports-2019-100579">kept off the playing field substantially longer</a>, standardized <a href="https://doi.org/10.1136/bjsports-2017-097699">assessment protocols are widespread</a> and <a href="https://doi.org/10.1001/jama.2018.14165">rules are in place</a> to reduce concussion risk.</p>
<p>Findings from these studies will never grab headlines as the Super Bowl does, and some may say that policy changes should <a href="https://www.economist.com/international/2019/01/26/few-sports-are-doing-enough-to-protect-athletes-from-brain-damage">happen faster</a>. Admittedly, the scientific process is slow, but decisions based on limited research are rarely, if ever, the right decision. But one day, this largely unheralded work will keep sports safe and its participants whole in body and mind.</p><img src="https://counter.theconversation.com/content/176541/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Steven P. Broglio has current or past research funding from the National Institutes of Health; Centers for Disease Control and Prevention; Department of Defense - USA Medical Research Acquisition Activity, National Collegiate Athletic Association; National Athletic Trainers’ Association Foundation; National Football League/Under Armour/GE; Simbex; and ElmindA. He is co-author of Biomechanics of Injury (3rd edition, Human Kinetics) and he has consulted for US Soccer (paid), US Cycling (unpaid), medico-legal litigation, and received speaker honorarium and travel reimbursements for talks given. He is co-author of “Biomechanics of Injury (3rd edition)” and has a patent pending on “Brain Metabolism Monitoring Through CCO Measurements Using All-Fiber-Integrated Super-Continuum Source” ( U.S. Application No. 17/164,490)</span></em></p>Millions of sports-related concussions occur in the US every year. Many of them happen to high school and college athletes.Steven P. Broglio, Professor of Kinesiology, Neurology, Physical Medicine and Rehabilitation, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1742222022-01-26T19:58:40Z2022-01-26T19:58:40ZConcussion management is changing as more research suggests exercise is best approach<figure><img src="https://images.theconversation.com/files/442339/original/file-20220124-27-rrhb4u.jpg?ixlib=rb-1.1.0&rect=208%2C6%2C3525%2C2146&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Concussion patients were once prescribed rest in a dark room, but in recent years concussion management has literally come out of the dark.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/concussion-management-is-changing-as-more-research-suggests-exercise-is-best-approach" width="100%" height="400"></iframe>
<p><a href="http://doi.org/10.1212/01.wnl.0000801820.38637.38">Public interest in concussion has exploded over the space of a generation</a>, together with a new understanding of how best to help patients recover. Concussion patients were once prescribed rest in a dark room, but in recent years concussion management has literally come out of the dark.</p>
<p>This is in large part because of a research boom: the number of studies on this mild form of traumatic brain injury has <a href="https://pubmed.ncbi.nlm.nih.gov/?term=concussion&timeline=expanded">multiplied by 15 times over the last 20 years</a>. This spike is a sign that the relatively young field of concussion research is maturing into a deeper science. It has created new evidence to support an entirely new approach to treating concussion. A recent wave of research papers has turned old practices on their heads.</p>
<h2>Past approach: A dark room</h2>
<p>For many years, concussion management followed a <a href="http://doi.org/10.1001/jamaneurol.2018.0006">rest-is-best</a> approach.</p>
<p>Under this passive approach, patients were advised to avoid cognitive and physical activity until their symptoms naturally resolved, leading to the notion that a dark room was the best environment for recovery.</p>
<figure class="align-center ">
<img alt="Two soccer players colliding while trying to head a ball" src="https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&rect=182%2C0%2C3771%2C2795&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442147/original/file-20220124-27-15ph81j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The number of research papers on concussion management has increased greatly over the last 20 years, leading to new approaches to treatment.</span>
<span class="attribution"><span class="source">(AP Photo/Phelan M. Ebenhack)</span></span>
</figcaption>
</figure>
<p>The problem was that there was scant evidence to support the dark-room method.</p>
<p>The motivation for using rest as a concussion-management strategy was a desire to <a href="https://doi.org/10.3928/00904481-20120827-12">limit exposure to environments and activities that might lead to secondary concussions</a>, which can have compounding, longer-lasting effects. Avoiding secondary injury was prioritized over proactive recovery.</p>
<p>But we are now in the midst of a transformation in concussion management.</p>
<h2>Exercise is medicine</h2>
<p>In the past few years, scientists have started to study aerobic exercise (or cardio training) as a management strategy for concussion symptoms. This <a href="http://doi.org/10.1249/JSR.0000000000000505">exercise-is-medicine</a> approach is diametrically opposed to the rest-is-best status quo.</p>
<p><a href="https://doi.org/10.1249/mss.0000000000002663">Many studies</a> have examined the effects of sub-maximal (low-to-moderate intensity) aerobic exercise on concussion symptoms. This research confirms the utility and safety of such exercise for managing concussion symptoms, which vary between individuals, but they are typically categorized as <a href="http://dx.doi.org/10.1136/bjsports-2017-097699">somatic (or physical), cognitive, emotional and sleep-related</a>. They can be assessed using adult- and child-specific symptom scales.</p>
<figure class="align-center ">
<img alt="A man running on a treadmill while another man wearing a lanyard observes." src="https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442573/original/file-20220125-19-11lqfs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Prescribing exercise in concussion typically involves a baseline test.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p><a href="http://doi.org/10.1249/MSS.0000000000002663">An academic review</a> that summarizes the findings of individual studies shows that exercise is indeed one of the most effective, evidence-informed strategies for managing concussion symptoms. Beyond a brief period (24 to 48 hours) of rest after concussion, the science now suggests that exercise is more beneficial than rest.</p>
<p>Prescribing exercise in concussion typically involves a baseline test. The most widely studied tests require patients either to walk on a treadmill with the incline gradually increasing throughout the test or cycle on a stationary bicycle against progressively increasing resistance. </p>
<p>Patients exercise under supervision until they experience an increase in symptoms (<a href="https://doi.org/10.1097/JSM.0000000000000431">which research shows is transient and not associated with poor long-term outcome</a>) or are unable to continue exercising. The heart rate at the point where the test is terminated is noted, and patients are then prescribed an exercise program involving five to six days of aerobic exercise at an intensity equivalent to 80 per cent of the maximum heart rate achieved during the test.</p>
<h2>Ongoing research</h2>
<figure class="align-center ">
<img alt="Man sitting on grass with his eyes closed and his fingertips on his temples" src="https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442160/original/file-20220124-13-dseuqc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The motivation for using rest as a concussion-management strategy was a desire to limit exposure to environments and activities that might lead to secondary concussions.</span>
<span class="attribution"><span class="source">(Pexels/Kindel Media)</span></span>
</figcaption>
</figure>
<p>As a next step, scientists are hard at work trying to determine the exact mechanism by which such sub-maximal exercise improves concussion symptoms. <a href="https://doi.org/10.3233/NRE-172298">A leading hypothesis</a> is that the autonomic nervous system (which regulates involuntary physiological processes, such as heart rate and breathing) is disturbed following a concussion, with its two constituent sub-systems becoming “uncoupled.”</p>
<p>Sub-maximal aerobic exercise is thought to engage the autonomic nervous system in a way that helps restore balance to this critical command centre. Simply put, it looks like exercise can safely and effectively generate the biological change required to overcome the symptoms of concussion.</p>
<p>More research is needed to build on this growing base of exercise-concussion knowledge. We need to understand how different frequencies, intensities, times and types of exercise can lessen symptom burden.</p>
<figure class="align-right ">
<img alt="Illustration of a brain on a purple and blue background" src="https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=456&fit=crop&dpr=1 600w, https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=456&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=456&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=573&fit=crop&dpr=1 754w, https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=573&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/442165/original/file-20220124-21-1wbjqdr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=573&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Researchers need to know how exercise impacts brain function in concussion as.</span>
<span class="attribution"><span class="source">(Unsplash/Fakurian Design)</span></span>
</figcaption>
</figure>
<p>Other research, including my ongoing work at McMaster University, aims to develop understanding of the effects of exercise by studying its impacts not only on symptoms, but also on brain activity. We need to know how exercise impacts brain function in concussion as, after all, concussions are brain injuries.</p>
<p>This shift in concussion management may mean better care will become available for patients. It is also a story about the power of bold science, the type of science which questions accepted wisdom and rebuilds first principles using evidence.</p>
<p>Challenging norms by changing perspective can lead to new approaches and better outcomes. Sometimes, as in the case with concussion, the game needs to be changed.</p><img src="https://counter.theconversation.com/content/174222/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bhanu Sharma receives funding from the Canadian Institutes of Health Research. </span></em></p>For many years, concussion treatment followed a rest-is-best approach. But research now suggests that low-to-moderate intensity exercise is a safe and useful approach to managing concussion symptoms.Bhanu Sharma, Post Doctoral Fellow, Faculty of Engineering, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1681682021-12-14T13:26:48Z2021-12-14T13:26:48ZBlocking an immune system molecule in mice may help prevent long-term disabilities after traumatic brain injury<figure><img src="https://images.theconversation.com/files/436207/original/file-20211207-141213-17pbntd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2090%2C1432&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">An estimated 69 million people worldwide experience a traumatic brain injury every year.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/mri-brain-with-headache-royalty-free-image/938046810">Iaremenko/iStock via Getty Images Plus</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Blocking an immune system molecule that accumulates after traumatic brain injury could significantly reduce the injury’s detrimental effects, according to a recent mouse study <a href="https://gladstone.org/people/jeanne-paz">my neuroscience lab and I</a> published <a href="https://doi.org/10.1126/science.abj2685">in the journal Science</a>.</p>
<p>The <a href="https://courses.lumenlearning.com/teachereducationx92x1/chapter/cerebral-cortex/">cerebral cortex</a>, the part of the brain involved in thinking, memory and language, is often the primary site of head injury because it sits directly beneath the skull. However, we found that another region near the center of the brain that regulates sleep and attention, the <a href="https://doi.org/10.1016/j.neuron.2019.06.005">thalamus</a>, was even more damaged than the cortex months after the injury.</p>
<p>This may be due to increased levels of a molecule called C1q, which triggers a part of the immune system called the <a href="https://doi.org/10.1186/s12974-020-02024-8">classical complement pathway</a>. This pathway plays a key role in rapidly clearing pathogens and dead cells from the body and helps control the inflammatory immune response.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/BSypUV6QUNw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">A branch of the immune system called the complement system is composed of trillions of proteins that enhance immune response.</span></figcaption>
</figure>
<p>C1q plays both <a href="https://doi.org/10.1186/s12974-020-02024-8">helpful and harmful roles in the brain</a>. On the one hand, accumulation of C1q in the brain can trigger abnormal elimination of synapses – the structures that allow neurons to communicate with one another – and <a href="https://doi.org/10.1126/science.aad8373">contribute to neurodegenerative disease</a>. On the other hand, C1q is also involved in <a href="https://doi.org/10.1016/j.cell.2007.10.036">normal brain development</a> and <a href="https://doi.org/10.1186/s12974-018-1066-z">protects the central nervous system from infection</a>. </p>
<p>In the case of traumatic brain injury, we found that C1q lingered in the thalamus at abnormally high levels for months after the initial injury and was associated with inflammation, dysfunctional brain circuits and neuronal death. This suggests that higher levels of C1q in the thalamus could contribute to several long-term effects of traumatic brain injury, such as sleep disruption and epilepsy.</p>
<p>C1q does provide some protection for the brain during traumatic injury, however. When we used genetically engineered mice that lack C1q at the time of trauma, the brain injury appeared much worse. This suggests that C1q is likely very important right when the injury happens in preventing cell death.</p>
<p>We collaborated with scientists at the biopharmaceutical company Annexon Biosciences to see if we could avoid C1q’s detrimental effects without losing its protective ones. We found that treating mice with an antibody that blocks C1q 24 hours after brain injury prevented detrimental effects like chronic inflammation and neuronal loss in the thalamus. Additionally, antibody treatment helped restore disrupted <a href="https://doi.org/10.1016/j.cub.2018.03.046">sleep spindles</a> – these are normal brain rhythms during the early stages of sleep that are important for memory consolidation. It also prevented the development of <a href="https://www.ncbi.nlm.nih.gov/books/NBK98139/">epileptic spikes</a>, or abnormal fluctuations in brain activity, which can disrupt <a href="https://doi.org/10.1016/0013-4694(88)90004-1">cognition and behavior</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Illustration of IgM bound to antigens on the surface of a membrane and activating the C1 complex of the complement system." src="https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/436214/original/file-20211207-19-julmtx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">C1q is part of a larger structure called C1, colored here in violet. When activated, this C1 structure plays a role in attracting and activating immune cells to attack invaders and clear foreign and damaged debris.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/igm-mediated-complex-activation-molecular-model-royalty-free-image/1316978215">Juan Gaertner/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<h2>Why it matters</h2>
<p>Traumatic brain injury can happen to anyone. It affects <a href="https://doi.org/10.3171/2017.10.jns17352">69 million people worldwide per year</a> and is a <a href="https://www.who.int/mental_health/neurology/neurological_disorders_report_web.pdf">leading cause of disability</a> in children and adults. Yet there are currently no therapies available to prevent the long-term disabilities that can result from brain trauma, such as epilepsy, sleep disruption and sensory processing difficulty.</p>
<p>We believe that targeting C1q after a brain injury could have protective benefits and help prevent some of the devastating consequences. Our study also answered some big questions in the field about where and how changes happen in the brain after trauma, and which ones actually cause deficits.</p>
<h2>What still isn’t known</h2>
<p>It remains unknown whether blocking C1q could also prevent epileptic seizures that develop after severe traumatic brain injury. Researchers <a href="https://doi.org/10.1038/s41582-021-00461-4">are looking for biomarkers</a> that would help identify people at high risk of developing epilepsy and working to understand the basic mechanisms leading from <a href="https://doi.org/10.1007/s13311-021-01119-1">traumatic brain injury to epilepsy</a>. There is no cure yet for post-traumatic epilepsy.</p>
<h2>What’s next</h2>
<p>My lab will continue working to expand our understanding of what happens in the brain after injury. Next, we want to focus on whether we can target C1q to prevent the convulsive seizures often reported among people with severe traumatic brain injuries.</p>
<p>C1q inhibitors are currently being tested in clinical trials for an autoimmune disorder known as <a href="https://n.neurology.org/content/94/15_Supplement/763">Guillain-Barré syndrome</a>. This could help accelerate treatment development for patients with traumatic brain injury.</p><img src="https://counter.theconversation.com/content/168168/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeanne Paz receives funding from the Department of Defense and the NIH. This research was conducted collaboratively with Annexon Biosciences.</span></em></p>The molecule C1q has both protective and detrimental effects after traumatic brain injury. Blocking it after injury in mice restored normal brain rhythms during sleep and prevented epileptic spikes.Jeanne Paz, Associate Investigator at Gladstone Institutes and Associate Professor of Neurology, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1453952020-09-04T06:02:42Z2020-09-04T06:02:42ZHere’s what we know about CTE, the brain condition that affected Danny Frawley<p>News emerged this week former AFL footballer Danny Frawley was <a href="https://www.theage.com.au/sport/afl/danny-frawley-was-suffering-from-chronic-brain-disease-when-he-died-20200831-p55r3k.html">suffering from a brain disease</a> called CTE when he died last year, according to reports received by the Victorian Coroner.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1300412939732529152"}"></div></p>
<p>Chronic traumatic encephalopathy, or CTE, refers to changes in the brain that have been linked to repeated blows to the head, <a href="https://www.heraldsun.com.au/sport/afl/danny-frawleys-subtle-changes-can-now-be-understood-of-his-cte-diagnosis/news-story/4abf6e3be1448dbae8912878bd93ee31">sometimes seen in former players</a> of sports such as rugby and Australian and American football codes. It’s believed these changes relate to an abnormal buildup of a protein called “tau” in the brain, which can <a href="https://molecularneurodegeneration.biomedcentral.com/articles/10.1186/1750-1326-4-13">damage brain cells</a>. </p>
<p>Frawley’s is the second confirmed case of CTE in a former AFL player, while two former NRL players are also thought to have had the condition.</p>
<p>CTE has prompted concern among the media and public, and researchers still don’t fully understand the condition. It is not yet clear whether CTE is directly caused by repeated hits to the head, as the condition has also been found in people with no known history of repetitive brain trauma.</p>
<p>There’s been a big increase in research on the topic over the past decade, which will hopefully teach us more about the condition and its possible treatments. But this will only happen if more funding is given to scientists to study it.</p>
<h2>What are the symptoms?</h2>
<p>The prevalence of CTE is unknown. Although it’s believed to be more common in athletes who suffer repeated head injuries, there has been <a href="https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(19)30020-1/fulltext">no rigorous epidemiological study</a> to confirm this claim. This may be because there’s no consensus on how to diagnose it while someone is alive – CTE can currently only be diagnosed retrospectively via an autopsy of brain tissue.</p>
<p>What’s more, the symptoms attributed to CTE are common in the general population, and are <a href="https://pubmed.ncbi.nlm.nih.gov/31670780/">not specific to the condition</a>. They range from mental health issues such as depression and anxiety, to substance abuse, suicidal behaviour, and even marital problems. </p>
<p>Proponents of CTE argue it’s a <a href="https://pubmed.ncbi.nlm.nih.gov/25904048/">distinct neurodegenerative disease</a>, separate from conditions such as Alzheimer’s. But <a href="https://pubmed.ncbi.nlm.nih.gov/31670780/">other researchers say</a> the brain changes in CTE are not unique, not necessarily progressive, and not specific to people exposed to repeated brain injury.</p>
<h2>Where is the research up to?</h2>
<p>Significant strides have been made in developing tools that may help <a href="https://pubmed.ncbi.nlm.nih.gov/31287716/">diagnose or predict CTE</a> in living people. These include <a href="https://pubmed.ncbi.nlm.nih.gov/31904765/">brain imaging methods</a> that might allow for the early detection of the <a href="https://pubmed.ncbi.nlm.nih.gov/30969506/">specific tau changes</a> believed to occur in the condition. Other research has focused on <a href="https://pubmed.ncbi.nlm.nih.gov/32712945/">identifying genetic factors</a> that may make some individuals more susceptible to CTE.</p>
<p>Scientists have also been investigating potential treatments, both for the symptoms and the underlying biological causes of CTE. For example, our laboratory at Monash University’s Department of Neuroscience has found a drug called sodium selenate can <a href="https://pubmed.ncbi.nlm.nih.gov/25771151/">reduce the amount of abnormal forms of tau</a>. This drug is currently in clinical trials for Alzheimer’s and another condition called frontotemporal dementia. It has also been <a href="https://pubmed.ncbi.nlm.nih.gov/27163189/">shown</a> to reduce the extent of cognitive deficits in rodents with repeated mild brain trauma.</p>
<h2>Concussions can be devastating, even without CTE</h2>
<p>While Frawley’s tragic death has renewed the focus on CTE, it’s important to recognise there are other devastating neurological complications that may be more likely to result from repetitive head injury. In particular, the risk of suffering from persistent post-concussion symptoms such headache, dizziness, and fatigue appears to be <a href="https://pubmed.ncbi.nlm.nih.gov/25763565/">significantly greater</a> in people with a history of multiple concussions. </p>
<p>Risk of these symptoms persisting after a concussion appears to be particularly high if repeat concussions <a href="https://pubmed.ncbi.nlm.nih.gov/23753087/">happen in short succession</a>. Some researchers <a href="https://pubmed.ncbi.nlm.nih.gov/28641105/">think</a> the recently concussed brain may have a “window of increased vulnerability” to repeated concussion. However, the length of time, and the underlying biological causes, of this vulnerable period are not yet well understood.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/for-an-unlucky-10-of-people-with-concussion-the-symptoms-may-be-long-lasting-116825">For an unlucky 10% of people with concussion, the symptoms may be long-lasting</a>
</strong>
</em>
</p>
<hr>
<p>In sport, this creates a lot of uncertainty around when it’s OK for a previously concussed athlete to resume playing. Caution around allowing players to get back on the field is increasingly appreciated in some sporting codes, conveyed in the widely touted “<a href="https://www.afl.com.au/afl-education/concussion">when in doubt, sit them out</a>” message.</p>
<figure class="align-center ">
<img alt="A young person complaining of a headache" src="https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=316&fit=crop&dpr=1 600w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=316&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=316&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/356235/original/file-20200903-20-1dot5vo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">How long is long enough? Researchers are working on ways to identify when it’s safe for players to return to sport after a concussion.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>But what we don’t know yet is, for how long? In attempt to shed some light on this, our laboratory is investigating how new blood and MRI tests may be able to objectively indicate when the brain has recovered from concussion and is no longer in a vulnerable state, thereby allowing previously concussed athletes to resume playing. </p>
<p>In the meantime, we must use the current knowledge available to manage the risks from blows to the head. Many sports have implemented rule changes in an attempt to decrease the risk of brain injury, which is welcome. Some people have gone further, advocating for participation in collision or contact sports to be banned to prevent CTE.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sports-coaches-need-to-be-educated-about-concussion-to-keep-players-safe-on-the-field-61975">Sports coaches need to be educated about concussion to keep players safe on the field</a>
</strong>
</em>
</p>
<hr>
<p>But when considering this option, it’s important to emphasise evidence of CTE in people with no known history of repetitive brain trauma or collision sport participation. Further, there are many health benefits to participating in sport. In fact, exercise is considered a promising treatment strategy for both <a href="https://pubmed.ncbi.nlm.nih.gov/30239422/">concussion</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/27521273/">neurodegenerative</a> disorders.</p>
<p>While we wait for further discoveries about CTE, it’s important to carefully weigh the known negatives and positives of sport participation. The interaction between physical activity and brain health is complex; we cannot ignore the problem of repeated brain trauma in sports, but stopping participation in all contact sports will also not lead to optimal brain health. </p>
<p>Making informed, evidence-based decisions about risk and benefit needs to rely on objective data (of which we need much more) rather than media hype.</p><img src="https://counter.theconversation.com/content/145395/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richelle Mychasiuk receives funding from the Australian National Health and Medical Research Council and the Canadian Institutes for Health Research. </span></em></p><p class="fine-print"><em><span>Sandy Shultz receives funding from NHMRC. </span></em></p><p class="fine-print"><em><span>Stuart McDonald does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Although a great deal of research is still required, it may one day be possible to identify and treat people either with CTE, or at risk of it.Richelle Mychasiuk, Associate Professor (Research), Department of Neuroscience, Monash UniversitySandy Shultz, Associate Professor (Research), Department of Neuroscience, Monash UniversityStuart McDonald, Research Fellow, Department of Neuroscience, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1332092020-03-16T14:38:57Z2020-03-16T14:38:57ZSevere brain injuries: technology can tell what patients are thinking – here’s what to consider before using it<figure><img src="https://images.theconversation.com/files/320789/original/file-20200316-27648-1ge9oro.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5097%2C2874&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">fNIRS can be done at a patient's bedside. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/computer-screen-showing-mri-ct-image-1197120001">Gorodenkoff/ Shutterstock</a></span></figcaption></figure><p>When a person sustains a severe brain injury that leaves them unable to communicate, decisions about their treatment must be made for them. In some cases, these decisions can mean the difference between life and death. But <a href="https://www.frontiersin.org/articles/10.3389/fnins.2020.00105/full">new research</a> may have found a new way of communicating with patients who might otherwise have been unable to. </p>
<p>Researchers asked volunteers with normal brain function to imagine playing a game of tennis, which activates a specific area of the brain used for <a href="https://www.sciencedirect.com/topics/neuroscience/supplementary-motor-area">planning complex movements</a>. Researchers were able to see the brain activity using <a href="https://www.ncbi.nlm.nih.gov/pubmed/17366276">functional near-infrared spectroscopy</a> (fNIRS), which is a headset that, when placed on a patient’s head, uses beams of light to detect which <a href="https://www.ncbi.nlm.nih.gov/pubmed/17366276">areas of the brain are active</a>. </p>
<p>Volunteers were then told to imagine playing tennis to answer “yes” or to stay relaxed to answer “no”. If researchers saw activity in the brain’s <a href="https://www.sciencedirect.com/topics/neuroscience/supplementary-motor-area">supplementary motor area</a>, they knew the person was responding “yes”. This breakthrough could potentially give patients with severe brain damage the ability to communicate with doctors and family members – and could potentially transform how treatment decisions are made. </p>
<p>For example, if families can’t communicate with their loved one, they may feel pressure to make treatment decisions quickly to avoid leaving them “trapped” in a severely disabled state. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3185074/">Research has shown</a> that 50% of families who withdraw treatment do so within the first 72 hours of patient admission to hospital. This means that some patients who could have made a good recovery die. Communication could allow patients to convey what treatment they want early on.</p>
<p>This new research is a significant step forward from <a href="https://www.nature.com/articles/nrn3608">foundational neuroimaging studies</a> developed over the last decade. In these early studies, severely brain-injured patients thought to be unconscious were placed in a functional magnetic resonance imaging scanner (fMRI), and asked to imagine playing tennis, or navigating their homes. By imagining these specific scenarios, patients could show they were conscious. <a href="https://jnnp.bmj.com/content/87/5/485.long">Several studies</a> have shown almost 15% of patients thought to be in a persistent vegetative state – defined by a complete lack of awareness of the self or environment – are actually conscious, based on <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073717/">brain activity shown during scans</a>.</p>
<p>However, many severely brain injured patients <a href="https://academic.oup.com/brain/article/139/1/292/2468793">cannot be scanned using fMRI</a>, leaving them no way to communicate. By adapting the tennis task to fNIRS, researchers can safely and easily scan patients at the bedside, potentially meaning a greater number of patients could communicate with researchers at a time when important treatment decisions are being made.</p>
<h2>Important questions</h2>
<p>Though this method could ultimately allow patients to choose their own treatment, there are at least two conditions that must be met before fNIRS can be ethically applied in this way.</p>
<p>First, researchers need to ensure they’re interpreting a patient’s brain responses correctly. In the study, the researchers were correctly able to identify in volunteers without brain injury 79% of “yes” responses and 71% of “no” responses. But if we plan to administer treatment (or not) based on a patient’s response, how sure do we need to be that a patient has responded “yes” rather than “no”?</p>
<p>One approach is to think about the consequences of getting things wrong. If we ask a patient whether they prefer to watch hockey over football, 79% accuracy is probably enough, because the consequences of a mistake are minor. If we ask a patient if they’re depressed, 79% accuracy might also be acceptable, because the consequences of ignoring a depressed patient are potentially worse than offering treatment to someone who isn’t depressed. But if we’re asking a patient if they want to continue with life-sustaining treatment, we need to be very sure about their response.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320792/original/file-20200316-27643-o4of13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A brain injury might change our ability to make decisions.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/puzzle-head-brain-concept-human-face-269726339">ESB Professional/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Second, we need to be sure that the patient has the capacity to make the decision we’re asking them to make. We usually assume that otherwise healthy adults can make their own medical decisions. But a patient with dementia might have to demonstrate their ability to a doctor by showing they understand the decision and its consequences, and can communicate this understanding. But severe brain injuries can cause cognitive deficits – giving us reason to be sceptical of a patient’s decision-making ability, especially complex decisions about <a href="https://www.tandfonline.com/doi/abs/10.1080/21507740.2013.821189">life-sustaining treatment</a>.</p>
<p>Of course, a patient could have the capacity to decide to end their life. Patients have the <a href="https://www.nhs.uk/common-health-questions/nhs-services-and-treatments/do-i-have-the-right-to-refuse-treatment/">right to refuse treatment</a>, even if this is likely to result in their death. For example, a patient with terminal cancer may refuse chemotherapy. <a href="http://www.bbc.co.uk/ethics/euthanasia/overview/introduction.shtml">In some countries</a>, patients can be actively assisted by physicians in ending their own lives.</p>
<p>But asking a severely brain-injured patient to decide about life-sustaining treatment is different. In the cancer case, the patient’s diagnosis may be sudden, but death from cancer may not be imminent – giving them time to think about what treatment is best for them. In the assisted dying case, the patient’s death is imminent, but not sudden. They will have had time to reflect on their decision. But a severe brain injury is sudden, and death will be imminent without treatment.</p>
<p>It’s difficult to imagine a patient being able to understand and appreciate the consequences of a life-or-death decision given these circumstances. They may be in severe pain or distress, which may impair their ability to weigh their present suffering against the potential for recovery in the future. Research also suggests that people <a href="https://www.ncbi.nlm.nih.gov/pubmed/10390038">tend to overestimate</a> how much worse off their lives would be with a severe disability. A patient that initially views a life of severe disability as worse than death may <a href="https://bmjopen.bmj.com/content/1/1/e000039">see things differently</a> once they adjust to their circumstances.</p>
<p>However, using fNIRS to communicate with patients could still be incredibly useful for assessing a patient’s experiences, allowing them to report on symptoms, and <a href="https://link.springer.com/article/10.1007%2Fs10677-017-9836-8">express wishes or preferences</a>. Even without the ability to make decisions, people can still have values, desires and preferences which affect their quality of life, and we don’t need to presume decision-making capacity to take these preferences and wishes seriously.</p><img src="https://counter.theconversation.com/content/133209/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mackenzie Graham receives funding from the Wellcome Trust. </span></em></p>By imagining a unique scenario to answer “yes” or “no” questions, this research could potentially be used to communicate with locked-in patients.Mackenzie Graham, Research Fellow of Philosophy, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1204892020-01-31T13:00:41Z2020-01-31T13:00:41ZHow do woodpeckers avoid brain injury?<figure><img src="https://images.theconversation.com/files/289474/original/file-20190826-8864-dspebh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Male pileated woodpecker. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-pileated-woodpecker-766792819?src=PWmrx7ewEJXjEiBQudLEQQ-1-4">FotoRequest/Shutterstock.com</a></span></figcaption></figure><p>Slamming a beak against the trunk of a tree would seem like an activity that would cause headaches, jaw aches and serious neck and brain injuries. Yet woodpeckers can do this 20 times per second and suffer no ill effects. </p>
<p>Woodpeckers are found in forested areas worldwide, except in Australia. These birds have the unusual ability to use their beaks to hammer into the trunks of trees to make holes to extract insects and sap. Even more impressive they do this without hurting themselves. </p>
<p><a href="http://cb3m.eng.ucsd.edu/">We are materials scientists</a> who study biological substances like bones, skins, feathers and shells found in nature. We are interested in the skull and tongue bone structure of woodpeckers, because we think their unusual anatomy could yield insights that could help researchers develop better protective head gear for humans. </p>
<h2>Concussions in people</h2>
<p>Woodpeckers endure many high impact shocks to their heads as they peck. They have strong tail feathers and claws that help them keep their balance as their head moves toward the tree trunk at 7 meters – 23 feet – per second. Then, when their beak strikes, their heads slow down at about 1,200 times the force of gravity (g). All of this occurs without the woodpecker sustaining concussions or brain damage. </p>
<p>A concussion is a form of traumatic brain injury caused by repeated blows to the head. It is a common occurrence and happens frequently during contact sports like football or hockey. Repeated traumatic brain injury eventually causes a progressive brain disorder, <a href="https://www.ninds.nih.gov/Current-Research/Focus-Disorders/Traumatic-Brain-Injury">chronic traumatic encephalopathy (CTE)</a>, which is irreversible and results in symptoms such as memory loss, depression, impulsivity, aggressiveness and suicidal behavior. </p>
<p>The National Football League says concussions in football players occur at 80 g. So how do woodpeckers survive repeated 1,200 g impacts without harming their brain? </p>
<p>We have looked for the key secrets of the woodpecker’s ability to tolerate the high impact during the hammering. We studied the micro-structures of bones and then did a biomechanical analysis on the head. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/1kk7ngj6ccc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The impact of wood pecking ripples through the head, neck and body of the bird. The woodpecker must close its eyes as its beak hits the tree or its eyeballs would pop out.</span></figcaption>
</figure>
<h2>Unusual skull bone and tongue bone structures</h2>
<p>By comparing the skulls of woodpeckers and chickens, we discovered that <a href="https://doi.org/10.1016/j.jmbbm.2018.05.001">woodpeckers have impact-absorbing adaptations</a> that other birds do not have. This includes specialized skull bones, neck muscles, beaks and tongue bones. </p>
<p>The skull bones have a different chemical composition and density. For example, one structural adaptation is achieved through increasing the accumulation of minerals in the bones to make them stiffer and stronger compared to other birds. Surprisingly, the skull bone is very thin and there is less fluid that separates the brain from the skull bone than in other birds and animals. That would suggest that the skull is adapted to be harder and tougher at the same time. </p>
<p>Typically in the real-world materials science, there is a general trade-off between hardness and toughness. However, <a href="https://doi.org/10.1002/adts.201800152">having both hard and tough materials on the head lessens the amount of impact transferred to the brain</a>. A second different is that woodpeckers have less internal fluid surrounding the brain than other big animals. This helps to limit the motion of the brain during the pecking. The reduced amount of fluid has an effect that is analogous to the yolk of a hard-boiled egg, which won’t get damaged by shaking, compared to the yolk of a raw, uncooked egg. </p>
<p>Woodpeckers also have a bone embedded in their tongue that helps to extract insects from the trees. The unusual tongue wraps around the back of the skull and anchors at the front between the eyes. This configuration lets the tongue and its bone act as a spring, dampening the physical force and related vibrations.</p>
<h2>Different types of bone</h2>
<p>The stiffness and strength of a typical skeletal bone is due to a dense sheath of compact bone that encapsulated a porous, spongy bone. But the woodpecker’s tongue bone has the opposite structure: a flexible sheath and a harder core bone. <a href="https://doi.org/10.1016/j.actbio.2016.03.030">This inside-out configuration</a> provides better flexibility and can absorb higher impacts and vibrations. </p>
<p>Our work suggests that the woodpecker’s unusual skull and tongue bones are <a href="https://doi.org/10.1002/adma.201901561">an example of impact-resistant structures essential for protecting the woodpecker’s brain during pecking behavior</a>.</p>
<p>Currently, biologists and neuroscientists are actively working on <a href="https://doi.org/10.1371/journal.pone.0191526">studying the woodpecker’s brain</a> to see if there is any pathological evidence of brain injuries – like CTE in humans. We hope this research reveals whether there are other protective or healing mechanisms at play at the level of tissues or cells in woodpecker brains which will, we hope, reveal how to protect and heal human brain injuries. </p>
<p><em><a href="https://scholar.google.com/scholar?q=%22Joanna+M.+McKittrick%22">Professor Joanna McKittrick</a>, a pioneering engineer at the University of California San Diego and a renowned expert in materials science, passed away Nov. 15, 2019, shortly after completing this piece. She was 65. She was a passionate advocate for women and underrepresented students in STEM and a thoughtful mentor. A celebration of her life will be held on Friday, Jan. 31, 2020, beginning at 4 p.m. at the UC San Diego Faculty Club.</em></p><img src="https://counter.theconversation.com/content/120489/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Pecking holes in a solid wood tree trunk would give you a headache, if not serious brain damage. What special assets allow a woodpecker to do it?Joanna McKittrick, Professor of Mechanical and Aerospace Engineering, University of California, San DiegoJae-Young Jung, Postdoctoral Scholar of Orthopedic Surgery, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1220352019-10-10T12:46:03Z2019-10-10T12:46:03ZCould helmetless tackling training reduce football head injuries?<figure><img src="https://images.theconversation.com/files/296289/original/file-20191009-3894-1t2038e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A young football player holds his mouth guard.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boy-putting-his-mouth-guard-131180210?src=HSe99Ku-wSt0C-t7Lt68pA-1-3">Suzanne Tucker/Shutterstock.com</a></span></figcaption></figure><p>With football season well underway, there already have been instances of helmet-to-helmet hits, concussions and yet another round of conversations about strategies to reduce head impact exposure in players. </p>
<p>This is an urgent matter for all football players, but particularly for the <a href="https://www.nytimes.com/2018/10/29/sports/football-participation.html">1.1 million high schoolers</a> who play, as well as for thousands more youngsters who play at even younger ages, hoping to one day find gridiron glory. Football is the <a href="https://rapidcityjournal.com/news/local/as-brain-injury-research-expands-football-participation-falls-in-s/article_f43a125c-ca0b-5294-9820-c4eb79d9d61e.html">most widely played</a> high school sport – and the <a href="https://news.gallup.com/poll/224864/football-americans-favorite-sport-watch.aspx">most popular spectator sport</a> in the country.</p>
<p>Because of the growing concern about concussions, many people argue that <a href="https://bioethics.georgetown.edu/2015/12/should-high-school-football-be-banned/">tackle football should be banned</a>. Opponents to this argue that tackle football is safer now, that coaches teach tackling differently. They argue that safer methods are reducing head impacts and the concussions that come with them. Yet, what are “safe” tackling techniques, and what does the data tell us about their impact on preventing concussions?</p>
<p>There is very little scientific evidence available to support claims that teaching tackling a certain way results in decreased head impacts, concussions or other injury. </p>
<p>I am <a href="https://scholar.google.com/citations?view_op=list_works&hl=en&user=ZiCI3uYAAAAJ">professor of kinesiology</a> who has studied spine injury and concussions in football throughout my career. Colleagues and I recently conducted and published a <a href="https://www.jsams.org/article/S1440-2440(18)31067-3/abstract">study</a> of high school students in an effort to see if a certain type of training can in fact protect athletes. Combined with an earlier study on the <a href="https://natajournals.org/doi/full/10.4085/1062-6050-51.1.06">college</a> level, the findings suggest that we are only beginning to answer these questions.</p>
<h2>A growing concern</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=434&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=434&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296291/original/file-20191009-3887-yg4u8l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=434&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Football helmets have been a mainstay of the sport since its inception.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/football-player-raises-his-helmet-before-83208013?src=n47gB67rNV1p39md5hTiqA-1-51">Brocreative/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Overall participation in high school football <a href="https://rapidcityjournal.com/news/local/as-brain-injury-research-expands-football-participation-falls-in-s/article_f43a125c-ca0b-5294-9820-c4eb79d9d61e.html">dropped 5.2%</a> last year. Some programs have even been canceled due to lower numbers that are further hampered by injury. For example, both <a href="https://www.nbcwashington.com/news/local/Maryland-High-School-Cancels-Varsity-Football-Season-for-Lack-of-Players-562021491.html">Thomas Jefferson High School</a> and <a href="https://www.nytimes.com/2019/10/09/sports/grinnell-football-season-canceled.html#click=https://t.co/EDtFIYK9ZK">Grinnell College</a> ended their seasons this October because of injuries. </p>
<p>While the use of theoretical safer tackling techniques, such as shoulder tackling, are anecdotally in widespread use, what scientific evidence is there to show they are truly safer? Do we really know, beyond chance, if a tackling technique results in the reduced concussions or the head impacts that cause them? As scientists, we just don’t know whether training tackling a specific way can truly reduce head impacts and concussion.</p>
<p>In the meantime, some of us wonder whether the answer could lie in helmetless tackling training.</p>
<p>To understand how helmetless tackling could help, it may first help to understand the concept of <a href="https://journals.lww.com/cjsportsmed/Fulltext/2004/07000/Risk_Compensation__A__Side_Effect__of_Sport_Injury.1.a">risk compensation</a>, the theory that helmetless tackling training is based on. </p>
<p>Risk compensation is a concept that goes at least as far back as when seat belts were first being mandated for drivers and passengers of cars. The thought was that adding seat belts caused a change <a href="https://www.sciencedirect.com/science/article/abs/pii/0001457594900957?via%3Dihub">in driving behavior</a>, which actually increased the frequency of motor vehicle <a href="https://link.springer.com/article/10.1007/BF00138059">accidents</a> because drivers felt safer. </p>
<p>In the case of football, the modern helmet creates a perceived reduction of risk, allowing the participant to initiate head first tackling and blocking. In other words, a football helmet – while necessary for traumatic head injury protection – contributes to an increase in risk-taking behaviors, such as head-first contact during a tackle or block. </p>
<p>A clear example of this phenomenon occurred after hard-shell helmets were introduced into football. <a href="https://www.ncbi.nlm.nih.gov/pubmed/434291">“Spear-tackling” behavior emerged</a>, leading to a spike in catastrophic head and neck injuries. </p>
<p>Rule changes in 1976 prohibited spear-tackling – the lowering of the head to make a tackle – which <a href="https://www.ncbi.nlm.nih.gov/pubmed/27432138">reduced head and spine injury</a> over 50%. However, football remains a helmet-centric sport and headfirst contact <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2707068/">continues</a>. </p>
<p>Contrast this against another sport that involves a lot of tackling: rugby. While rugby players are definitely prone to <a href="https://doi.org/10.1016/j.jemermed.2018.11.007">sustaining concussions</a>, American football is beginning to model the rugby style tackle of using their shoulders to initiate contact while avoiding head contact. </p>
<p>Based on risk compensation theory, rugby players tackle with their shoulders not only because they were taught that way, but because their heads are not protected with a helmet. Keeping the head out of the way simply develops naturally as an <a href="https://www.sciencedirect.com/science/article/pii/S0304394004006159">anticipatory reflex</a> to <a href="https://www.degruyter.com/view/j/revneuro.2004.15.5/revneuro.2004.15.5.371/revneuro.2004.15.5.371.xml">protect</a> the head. </p>
<h2>Helmetless tackling</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296292/original/file-20191009-3917-1anqc9t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Young football players learn some of the basics of the game, without helmets.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/bakersfield-ca-june-9-coaches-teach-104775533?src=SQFvG0LqpVnOKSQ0LqvUXA-1-2">Richard Thornton/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>Our research is based on the hypothesis that a football player who regularly receives tackling and blocking training without wearing a helmet will reinforce motor behaviors for avoiding head impacts with other players. </p>
<p>Adopting and mastering this skill could counter the inclination to initiate head-first tackling and blocking when wearing a helmet. </p>
<p>Using a randomized study, we found college players assigned to a helmetless training group decreased their head impacts compared to a control group by <a href="https://doi.org/10.4085/1062-6050-51.1.06">30% at the end of the season</a>. In a larger <a href="https://natajournals.org/doi/full/10.4085/1062-6050-51.1.06">study in high school players</a>, we found subjects who participated in helmetless tackling training to have fewer head impacts in the middle of the season in two successive years, mostly during games. This difference did not hold up by the end of the season, however. </p>
<p>We also compared the subjects in our study who were freshmen separately from those who competed on the junior varsity and varsity levels. When we analyzed the data that way, the reduction in head impacts appeared to only be coming from the older, or varsity, players. This may suggest that the younger, less experienced players could need a higher frequency, or dose, of the helmetless training.</p>
<p>Clearly, researchers need to do more work to fully understand the kind of training, and how much training, is needed depending on the age and experience level of the player to get the desired results. </p>
<p>Either way, this research represents the only prospective randomized, controlled studies to our knowledge, to have explored the outcomes of a tackling training technique in football. </p>
<h2>The need for randomized controlled trials</h2>
<p>Importantly, head impacts and concussions suffered from tackling and blocking involves more than just teaching a sport skill. This is not to suggest that teaching sport skills is simple. Rather, it suggests that head impact exposure in football is a medical problem, and just like any other medical problem, needs a medical solution. </p>
<p>As with over the counter or prescription medications and medical devices, federally mandated rigorous study using randomized controlled trials are the norm for demonstrating a cause effect relationship. Given the populations involved, and number of participants playing football, rigorous research using randomized controlled trials is warranted. </p>
<p>Those of us who study this problem do not yet know whether new tackling techniques are truly safer, but we do know that players, especially young ones, deserve to know. </p>
<p>[ <em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/122035/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Erik Swartz currently receives funding from The GOG Foundation. He has previously received funding from The National Football League, General Electric, and UnderArmor (NineSigma Head Health Challenge), and the National Athletic Trainers' Association. HUTT is a USPTO registered trademark of the University of New Hampshire. </span></em></p>Football participation among high schoolers continues to decline, as concern about brain injury increases. Could training without helmets make a difference?Erik Swartz, Professor of Kinesiology, UMass LowellLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219432019-09-22T20:12:39Z2019-09-22T20:12:39ZIn a chatty world, losing your speech can be alienating. But there’s help<figure><img src="https://images.theconversation.com/files/293107/original/file-20190919-187967-16wimgh.jpg?ixlib=rb-1.1.0&rect=14%2C44%2C4977%2C4947&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People who have trouble with their speech, say after a stroke, can find it challenging. But a speech pathologist can help.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/thought-process-94692049?src=btrjmq_1pd93BryAC4MCkg-1-69">from www.shutterstock.com</a></span></figcaption></figure><p>Sam is a high school drama teacher — articulate, funny, smart. It’s an ordinary day and she isn’t feeling great, but pushes through. At morning tea, she spills coffee down her shirt; at lunch she notices a strange sensation in her lips and tongue. Then her speech starts to sound odd, slurred, indistinct. </p>
<p>Sam is having a stroke. In the following months, her speech is still painstakingly slow, full of mistakes, hard to understand.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-recognise-a-stroke-and-what-you-should-know-about-their-treatment-63651">How to recognise a stroke and what you should know about their treatment</a>
</strong>
</em>
</p>
<hr>
<p>Sam is still funny and smart but no-one can see that. She can’t work. Her friends are impatient or embarrassed, condescending at times, and they gradually disappear. </p>
<p>Fortunately, help is available. But the path to recovery will test Sam’s mettle and redefine her identity.</p>
<h2>How common are conditions like Sam’s?</h2>
<p>Speech disorders like Sam’s can affect people <a href="https://theconversation.com/how-to-tell-if-your-child-has-a-speech-or-language-impairment-31768">at any age</a>. But people aren’t generally aware these problems can arise as an adult.</p>
<p>In Australia, someone has a stroke <a href="https://strokefoundation.org.au/About-Stroke/Facts-and-figures-about-stroke">every nine minutes</a>. That means about 153 people have a stroke every day. <a href="https://doi.org/10.1111/ijs.12067">Up to 70%</a> of people who survive a stroke cannot speak clearly and intelligibly. For about <a href="https://doi.org/10.1111/ijs.12067">a quarter</a> of these stroke survivors, these effects persist for months to years.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/293128/original/file-20190919-187957-2ezd93.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">About a third of stroke survivors are under the age of 65, like this man who now has an asymmetrical face, and whose speech might be impaired.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/symptom-stroke-cerebral-asymmetry-face-angioedema-1039278820?src=xa8W8wubPe3b_d38sZ6FSQ-1-2">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>While stroke is most common in the elderly, <a href="https://strokefoundation.org.au/About-Stroke/Facts-and-figures-about-stroke">30% of stroke survivors</a> are under the age of 65. </p>
<p>Acquired speech disorders are even more common in other conditions. <a href="https://docs.wixstatic.com/ugd/bfe057_f0e5647adc1246e388550ebbefd9760f.pdf">About 50%</a> of people with Parkinson’s disease, <a href="https://www.ncbi.nlm.nih.gov/pubmed/10782009">up to 50%</a> with multiple sclerosis, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/28121021">as many as 65%</a> with a traumatic brain injury have them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-traumatic-brain-injury-75546">Explainer: what is traumatic brain injury?</a>
</strong>
</em>
</p>
<hr>
<h2>What’s causing Sam’s difficulties?</h2>
<p>Sam’s stroke damaged the area of the brain that controls her mouth movements, causing a <a href="https://nucasll.northwestern.edu/motor-speech-disorders">motor speech disorder</a>. There are different types. But Sam has the type called <a href="https://www.asha.org/public/speech/disorders/Apraxia-of-Speech-in-Adults/">apraxia of speech</a>. Her muscles still work fine for eating but, when it comes to speech, she can no longer control precisely where they move and when.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-tell-if-your-child-has-a-speech-or-language-impairment-31768">How to tell if your child has a speech or language impairment</a>
</strong>
</em>
</p>
<hr>
<p>Other types of motor speech disorders are called <a href="https://www.asha.org/public/speech/disorders/dysarthria/">dysarthrias</a> and can make the muscles too tense, too relaxed, or limited in their range of movement.</p>
<p>Motor speech disorders are different to language disorders, called <a href="https://www.asha.org/public/speech/disorders/Aphasia/">aphasia</a>. Aphasia affects your ability to find the right words and sentences to convey your ideas or to understand what others say to you. However, motor speech disorders and aphasia can occur together.</p>
<h2>The effects can go beyond losing your speech</h2>
<p>Sam told me, as part of yet-to-be published research, out of all the difficulties after her stroke:</p>
<blockquote>
<p>[…] speech was by far the most alienating one.</p>
</blockquote>
<p>If you lose your speech, you can lose your job, your social network, your independence, your identity. Some have likened it to being in a foreign country and not being able to <a href="https://doi.org/10.1080/17549507.2018.1415548">communicate</a> at all. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/stroke-survivors-and-their-carers-often-have-poor-mental-health-heres-how-we-can-help-them-80606">Stroke survivors and their carers often have poor mental health. Here's how we can help them</a>
</strong>
</em>
</p>
<hr>
<p>But it’s not quite the same. People with motor speech disorders often can understand everything you say. They want to respond and contribute to the conversation, but their disorder means people don’t understand what they say or they speak too slowly.</p>
<p>In this example, someone with a motor speech disorder, like the one Sam has, finds it difficult to say longer, more complex words. The person is saying “the municipal judge sentenced the criminal”.</p>
<p><audio preload="metadata" controls="controls" data-duration="12" data-image="" data-title="" data-size="285244" data-source="Author provided" data-source-url="" data-license="Author provided" data-license-url="">
<source src="https://cdn.theconversation.com/audio/1731/speech-sample-the-municipal-judge-01.mp3" type="audio/mpeg">
</audio>
<div class="audio-player-caption">
<span class="attribution"><span class="source">Author provided</span>, <span class="license">Author provided</span><span class="download"><span>279 KB</span> <a target="_blank" href="https://cdn.theconversation.com/audio/1731/speech-sample-the-municipal-judge-01.mp3">(download)</a></span></span>
</div></p>
<h2>If you lose your speech, what can you do?</h2>
<p>People rarely realise learning to speak required thousands of hours of practice. By the time children turn four, they produce on average <a href="https://doi.org/10.1044/2016_AJSLP-15-0169">1,900 speech vocalisations a day</a>. These not only include words, but also phrases produced on one breath.</p>
<p>But you can’t remember this, so developing your speech seemed effortless. In fact, most of us take our speech for granted.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-why-the-human-voice-is-so-versatile-69800">Explainer: Why the human voice is so versatile</a>
</strong>
</em>
</p>
<hr>
<p>The good news is, speech is like any other complex motor skill. It is like swimming or playing the piano, or <a href="https://www.archives-pmr.org/article/S0003-9993(19)30508-8/fulltext">relearning to walk</a> after a stroke. If you use it, <a href="https://doi.org/10.1044/1092-4388(2008/018)">you can improve it</a>.</p>
<p>As Sam realised:</p>
<blockquote>
<p>If I work as hard as I can, there’s no way I can’t get a little better.</p>
</blockquote>
<h2>What type of therapist do I need?</h2>
<p>So, what type of help is available? A good place to start is a <a href="https://www.speechpathologyaustralia.org.au/SPAweb/Resources_for_the_Public/Find_a_Speech_Pathologist/SPAweb">speech pathologist</a>. </p>
<p>You can find one in hospitals, rehabilitation centres and in the community. They work with you to build a program of practice and activities to improve your speech.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/293122/original/file-20190919-187967-i5d68j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A speech pathologist will work with you to build a program of activities and practice to improve your speech.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-man-consulting-medical-doctor-psychologist-672388090?src=ZxprDmQoihgdU3U8R_kf-w-1-21">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>While relearning to speak is not easy, <a href="https://www.tandfonline.com/doi/full/10.1080/09638288.2018.1497714">we now</a> <a href="https://pubs.asha.org/doi/10.1044/2015_AJSLP-14-0118">know people respond</a> to carefully structured therapy that stimulates activity in the undamaged parts of the brain that control movements needed for speech. </p>
<p><a href="https://pubs.asha.org/doi/10.1044/1058-0360%282008/025%29">This therapy</a> <a href="https://pubs.asha.org/doi/10.1044/2015_AJSLP-14-0118">looks and feels</a> like training programs for <a href="https://www.archives-pmr.org/article/S0003-9993(19)30508-8/fulltext">other complex motor skills</a>: practising multiple times a week, at moderate intensity, <a href="https://pubs.asha.org/doi/10.1044/1092-4388%282008/018%29">using the targeted</a> skills and behaviours in a range of activities and contexts. </p>
<p>For instance, a typical session might involve practising useful words or phrases (by yourself or out in the community), making sure you use all the right sounds, over-enunciating, and gradually speeding up to sound more natural.</p>
<h2>Not everyone can access therapy</h2>
<p>But there’s a problem. Most people can’t afford one-on-one sessions with a “trainer” or therapist for multiple practice sessions a week. And it’s uncommon for a speech pathologist to work with a patient for months at a time.</p>
<p>According to Speech Pathology Australia’s <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Speech_Pathology/Submissions">submission</a> (submission 224) to a Senate committee into speech pathology services, specialist services for adults with speech disorders are “extremely limited”.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/293126/original/file-20190919-187991-k35169.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The support of friends and family is critical in helping people on the long road to recovering their speech.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-couple-looking-each-other-closeup-1271113900?src=DetVrAbgrVPitZT1BTdNHg-1-96">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>While health-care systems and funding may support people in the early stages after a stroke or injury, the submission continues “long term help available in the community, and support for communication are severely lacking”. </p>
<p>This situation is perplexing given a communication disorder has a “huge impact on an individual’s productivity and participation”. </p>
<h2>What happened to Sam?</h2>
<p>This was Sam’s experience of working with a speech pathologist. She told me:</p>
<blockquote>
<p>First you have […] contact but then it’s expensive. </p>
</blockquote>
<p>Sam and her family soon realised the ball was in their court:</p>
<blockquote>
<p>That’s how it all started – taking accountability for my own recovery. The most important thing for me was knowing it’s possible – instilling hope. </p>
</blockquote>
<p>Sam used what she had learned in her speech therapy sessions. Combined with her intelligence, common sense, tenacity, and her family and friends, she created her own rehabilitation program. </p>
<p>It included a range of exercises to target specific skills, such as challenging words, speech rhythm, and fluency in conversation. She practised every day in different environments — at home, out with friends, in noisy and quiet environments. She used different supports, sometimes a notepad, other times a phone app. </p>
<p>Like a personal training program at the gym, she has done this every day, ever since.</p>
<p>It is now nine years since Sam’s stroke. She’s back working. Her speech, most of the time, doesn’t attract attention. She trips over the occasional longer word (legitimatise is one recent example) and her speech can sound a little drunken if she gets over-tired. She says, it was perhaps the greatest challenge of her life but worth the fight.</p>
<h2>What could we do better for people like Sam?</h2>
<p>Sam is just one example of how the current health-care model of rehabilitation services for people with long-term communication difficulties is not fit for purpose.</p>
<p>Sam embraced the challenge to create her own program but for many this is overwhelming. </p>
<p>The predominant model of therapy, heavily supervised by an expert clinician, needs to change. Instead, we need to encourage a person’s “ownership” of their own recovery, encourage people to share accountability for therapy goals and outcomes with clinicians, have programs available in the community, and support people to build a strong network of family, friends and colleagues.</p>
<p>A speech pathologist is a critical member of the team. But people with speech disorders will be disadvantaged until we embrace models of care like Sam’s.</p>
<hr>
<p><em>Find an Australian speech pathologist <a href="https://www.speechpathologyaustralia.org.au/SPAweb/Resources_for_the_Public/Find_a_Speech_Pathologist/SPAweb/Resources_for_the_Public/Find_a_Speech_Pathologist/All_Searches.aspx?hkey=0b04c883-80b2-43e7-9298-7e5db5c75197">near you</a>. Paid and free resources about motor speech disorders are <a href="https://tactustherapy.com/dysarthria/">also available</a>.</em></p>
<p><em>Editor’s note: the quotes used in this article are from the author’s research, but personal details including name and background have been changed to protect privacy.</em></p><img src="https://counter.theconversation.com/content/121943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kirrie J Ballard receives funding from The Australian Research Council, National Institutes of Health (USA), Qatar National Research Fund, and Multiple Sclerosis Research Australia. She is affiliated with Speech Pathology Australia as a Fellow of the Association and as Editor of their scholarly journal; America Speech Language and Hearing Association as a certified practising member; Academy of Neurological Communication Disorders and Sciences as a member at large and member of two evidence-based practice writing committees; and International Association of Logopaedics and Phoniatrics, as a member of the Committee on Motor Speech Disorders.</span></em></p>When people lose their speech, they can stop working and friends can drift away. Here’s what we can do to help them get the rehabilitation they need.Kirrie J Ballard, Professor, Speech Pathology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1169822019-05-24T10:44:42Z2019-05-24T10:44:42ZPeople with traumatic brain injury, who often lose empathy, can regain it with treatment<figure><img src="https://images.theconversation.com/files/275953/original/file-20190522-187165-7bot3u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Understanding the facial cues from another person is a component of empathy.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sad-man-listening-advice-colleague-during-690911812?src=YLMUcA7ngh2FRkp9dGmLiw-1-76">Pressmaster/Shutterstock.com</a></span></figcaption></figure><p>Most people can easily determine when a loved one is feeling sad or anxious. This recognition will often trigger the person to offer a comforting gesture or even have a <a href="https://en.wikipedia.org/wiki/Emotional_contagion">contagious emotional</a> reaction, causing them to also feel sad or anxious, too. </p>
<p>These important actions are referred to as emotion recognition and empathy, and they are fundamental to establishing human emotional connections and relationships.</p>
<p>But imagine waking up one morning and your loved one lost the ability to recognize and empathize with your feelings. For the last couple of decades, researchers have been showing this to be a common outcome for people who have suffered a traumatic brain injury. The inability to <a href="https://psycnet.apa.org/record/2011-06479-001">recognize</a> and <a href="https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/inability-to-empathize-following-traumatic-brain-injury/A3AA1F6B946F6A71F156BF76D3E7FE2A">empathize</a> with others’ emotions after brain injury has a resounding impact on family and friends and has sparked research leading to promising treatments.</p>
<p>I started studying emotion recognition and empathy in 2005, and this is exactly how the wife of my first research participant described it happened for her husband who was in a car accident and suffered a traumatic brain injury, or TBI. Once a very affectionate partner who responded to all of her emotional needs, he now failed to recognize her sadness or comfort her when she lost her father. Conversely, he was unable to feel the emotional contagion of her joy when she received recognition at work. This once very strong couple later divorced.</p>
<h2>Crashes, blasts and falls that affect millions</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275952/original/file-20190522-187153-1wmlwep.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Falls are a common cause of traumatic brain injury, but car and motorcycle crashes also are major causes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/construction-worker-falling-off-ladder-inside-521522911?src=INAi_gpaECFoioEX2l7XOA-1-35">Andre Marcelo Santa Maria/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>A <a href="https://www.biausa.org/brain-injury/about-brain-injury/basics/overview">TBI</a> is when an external physical force leads to a disruption in brain function. Falls and motor vehicle accidents are the most common causes, but damage also results from many other injuries, including blast injuries that are frequently experienced by active duty military. </p>
<p>In 2014, almost <a href="https://www.cdc.gov/traumaticbraininjury/get_the_facts.html">3 million Americans</a> received some type of medical care or died from a TBI-related incident. Problems with attention, memory, planning, reasoning or problem solving are common. But often more troublesome are the frequent emotional and behavioral changes, such as increased anger and aggression. Emotional and behavioral changes have been linked with problems recognizing others’ emotions and an inability to share another’s feelings. </p>
<p>Prevalence rates of <a href="https://psycnet.apa.org/record/2011-06479-001">problems with emotion recognition</a> and <a href="https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/inability-to-empathize-following-traumatic-brain-injury/A3AA1F6B946F6A71F156BF76D3E7FE2A">decreased empathy</a> after brain injury are 39% and 60%, respectively. </p>
<p>This is quite concerning for people with TBI and their family members, as this impairment has been related to worse <a href="https://www.tandfonline.com/doi/abs/10.1080/02699052.2018.1531301">social relations</a> after TBI. </p>
<h2>The first step of empathy</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/275955/original/file-20190522-187189-tut1fk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A boy responds to a girl’s look of pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-boy-hugging-consoling-upset-girl-1164198340?src=YLMUcA7ngh2FRkp9dGmLiw-1-46">fizkes/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>It has been a longstanding <a href="https://journals.sagepub.com/doi/abs/10.1177/1534582304267187">theory</a> that a person must recognize others’ emotions in order to empathize with them.</p>
<p>However, despite the strong theoretical rationale, scientific experiments have had trouble finding strong support for this belief, in people <a href="https://journals.lww.com/headtraumarehab/Abstract/2014/01000/Relationships_Between_Alexithymia,_Affect.13.aspx">with</a> and <a href="https://www.safetylit.org/citations/index.php?fuseaction=citations.viewdetails&citationIds%5B%5D=citjournalarticle_261580_38">without</a> brain injury. </p>
<p>When I looked at how the past studies were conducted, I saw clear design flaws. Many of the former studies assessed emotion recognition and empathy in isolation of one another. Empathy was typically measured with unrelated subjective questionnaires. So it is not too surprising little relationship was found between two unrelated tests. </p>
<p>For example, researchers would administer an emotion recognition test, such as pictures of facial expressions. The researchers would then give participants a questionnaire about their general empathic tendencies. But the researchers did not test how the person with TBI felt in response to the facial expressions they had to identify. For example, did they feel sad when looking at a sad person? By not gauging a person’s feelings in response to the emotional expression in the picture, researchers were not measuring a direct empathic response to another’s feelings. </p>
<h2>A second step to empathy</h2>
<p>Due to the limitations of previous studies, my colleague, <a href="https://spectre.cqu.edu.au/profiles/view/10920"></a><a href="https://scholar.google.com/scholar?hl=en&as_sdt=0%2C15&q=barbra+zupan&btnG=&oq=barbra+z">Dr. Barbra Zupan</a>, and I decided to take a different approach. In our <a href="https://doi.org/10.1016/j.apmr.2018.07.431">recent publication</a>, we showed subjects with and without TBI emotional film clips and had them identify how the character in the clip felt and how they felt while watching the clip. </p>
<p>Since a shared emotional response is an element of empathy, when participants felt the same emotion they identified the character to be feeling, we defined that as an empathic response. We did not require them to recognize the character’s emotion accurately to be classified as an empathic response. Using this approach allowed us to measure the direct relationship between recognizing another’s emotion and having a shared empathic response. If we made accurate emotion recognition a requirement to be considered an empathic response, we would not have been able to measure this relationship. </p>
<p>We had several interesting findings. Based on past research showing <a href="https://www.cambridge.org/core/journals/journal-of-the-international-neuropsychological-society/article/inability-to-empathize-following-traumatic-brain-injury/A3AA1F6B946F6A71F156BF76D3E7FE2A">impaired empathy</a> after TBI, we expected the percent of empathic responses to be pretty low in our participants with TBI. While participants with TBI did not have as many empathic responses as their uninjured age and gender matched peers (79%), they did respond empathically 67% of the time. </p>
<p>Further, we found that accurate recognition of characters’ emotions was associated with a greater number of empathic responses. The empathic responses of participants with TBI more than doubled when they accurately identified the character’s emotion, compared to a misrecognized emotion (71% vs. 32%, respectively). </p>
<p>We think it is important to note that correct emotion recognition was not sufficient for an empathic response to occur in either group. That is, participants did not always respond empathically when they correctly recognized the emotion.</p>
<p>Our findings also suggest that participants with TBI had a harder time recognizing and empathizing with sad and fearful emotions, compared to happy emotions. This was indicated by their lower recognition and empathic responses when characters were acting sad and afraid. This means that when loved ones need comforting the most – when feeling fearful or sad – they are unlikely to get it from a partner with TBI.</p>
<h2>Helping those with TBI</h2>
<p>We think these findings have important clinical implications.</p>
<p>First, clinicians treating people with TBI should plan to evaluate emotion recognition and empathy in their patients and learn how to treat these impairments. Interviewing patients with TBI and their family members can help paint a picture of how a person has changed compared to his or her pre-injury self and lead to goals for rehabilitation. There are <a href="https://journals.lww.com/headtraumarehab/Abstract/2015/05000/A_Randomized_Controlled_Trial_of_Emotion.12.aspx">evidence-based approaches and free treatment tools</a>, designed by our group, that have now been deemed <a href="https://www.archives-pmr.org/article/S0003-9993(19)30194-7/abstract">practice standards</a> for improving emotion recognition skills. </p>
<p>When training emotion recognition after TBI, clinicians should also discuss with the patient ways they can respond empathically to loved ones. <a href="https://www.ingentaconnect.com/content/wk/htr/2017/00000032/00000005/art00010">Newer research</a> from another group in the Netherlands shows that this combination – both recognition and responding empathically – is effective and should involve the family member as part of treatment. </p>
<p>Also, clinicians should consider educating survivors of TBI and their families about these common changes after TBI, why it happens, what they might expect in terms of changes in behavior, and notifying them that it could improve with treatment. </p>
<p>Finally, family members could be directed to be more explicit about their emotions and what they would like from their loved one with a brain injury. Together, these efforts could improve outcomes after TBI and minimize the common relationship strains experienced after a brain injury.</p><img src="https://counter.theconversation.com/content/116982/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dawn Neumann has received funding from the Cannon Research Center at Carolinas Rehabilitation, The Humanity Research Institute at Brock University, and the National Institute on Disability, Independent Living and Rehabilitation Research (grant no. H133G080043)</span></em></p>Millions of people suffer traumatic brain injuries, and many lose the ability to emotionally connect with others. A new study suggests there’s a way to help them regain their ability to connect.Dawn Neumann, Associate Professor of Physical Medicine & Rehabilitation, IUPUILicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1129352019-03-15T10:43:13Z2019-03-15T10:43:13ZMarijuana is a lot more than just THC - a pharmacologist looks at the untapped healing compounds<figure><img src="https://images.theconversation.com/files/263129/original/file-20190311-86693-ga1zx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Assorted cannabis bud strains.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/assorted-cannabis-bud-strains-glass-jars-526723486">Roxana Gonzalez/Shutterstock.com</a></span></figcaption></figure><p>Medical marijuana is legal in 33 states as of November 2018. Yet the federal government still insists <a href="https://www.fda.gov/newsevents/publichealthfocus/ucm421168.htm">marijuana has no legal use</a> and is easy to abuse. In the meantime, medical marijuana dispensaries have an increasing array of products available for pain, anxiety, sex and more. </p>
<p>The glass counters and their jars of products in the dispensary resemble an 18th century pharmacy. Many strains for sale have evocative and magical names like Blue Dream, Bubba Kush and Chocolope. But what does it all mean? Are there really differences in the medical qualities of the various strains? Or, are the different strains with the fanciful names all just advertising gimmicks?</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=565&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=565&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=565&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=710&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=710&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263763/original/file-20190313-123538-x37pr9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=710&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Rafael, a Chumash who shared Californian Native American cultural knowledge with anthropologists in the 1800s.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/4/4e/Rafael%2C_a_Chumash_who_shared_cultural_knowledge_with_Anthropologists.jpg">Leon de Cessac</a></span>
</figcaption>
</figure>
<p>I am a professor in the University of Southern California School of Pharmacy. I have lived in California a long time and remember the Haight-Ashbury Summer of Love. While in graduate school, I worked with professor <a href="https://en.wikipedia.org/wiki/Alexander_Shulgin">Alexander Shulgin</a>, the father of designer drugs, who taught me the chemistry of medicinal plants. Afterwards, while a professor at USC, I learned <a href="http://doi.org/10.1093/ecam/neh072">Chumash healing</a> from a Native American Chumash healer for 14 years from 1998 until 2012. She taught me how to make medicines from Californian plants, but not marijuana, which is not native to the U.S. Currently, I am teaching a course in medical marijuana to pharmacy students. </p>
<p>If there is one thing about marijuana that is certain: In small doses it can boost libido in men and women, <a href="https://www.psychologytoday.com/us/blog/all-about-sex/201808/the-largest-best-studies-yet-sex-and-marijuana">leading to more sex</a>. But can marijuana really be used for medical conditions? </p>
<h2>What are cannabinoids?</h2>
<p>New research is revealing that marijuana is more than just a source of cannabinoids, chemicals that may bind to cannabinoid receptors in our brains, which are used to get high. The most well-known is tetrahydrocannabinol (THC). Marijuana is a particularly rich source of medicinal compounds that we have only begun to explore. In order to harness the full potential of the compounds in this plant, society needs to overcome misconceptions about marijuana and look at what research clearly says about the medical value.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=529&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=529&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=529&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=665&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=665&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263491/original/file-20190312-86703-17mhtg7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=665&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The dried bud of a Kush cannabis plant.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/b/b5/Kush_close.jpg">Kerouachomsky</a></span>
</figcaption>
</figure>
<p>The FDA has already made some moves in this direction by approving prescription drugs that come from marijuana including dronabinol, nabilone, nabiximols and cannabidiol. Dronabinol and nabilone are cannabinoids that are used for nausea. Nabiximols – which contain THC, the compound most responsible for marijuana’s high and cannabidiol, which does not induce a high – are used to treat <a href="https://www.ninds.nih.gov/Disorders/All-Disorders/Multiple-Sclerosis-Information-Page">multiple sclerosis</a>. Cannabidiol, or CBD, is also used to <a href="https://www.usatoday.com/story/news/nation-now/2018/06/26/fda-approves-first-cbd-oil-derived-marijuana-treat-epilepsy/733567002/">treat some types of epilepsy</a>.</p>
<p>Marijuana, originally from the Altai Mountains in Central and East Asia, contains at <a href="http://doi.org/10.1016/bs.apha.2017.03.004">least 85 cannabinoids</a> and <a href="http://doi.org/10.1016/bs.apha.2017.03.004">27 terpenes</a>, fragrant oils that are produced by many herbs and flowers that may be active, drug-like compounds. THC is the cannabinoid everyone wants in order to get high. It is produced from THC acid – which constitutes up to 25 percent of the plant’s dry weight – by smoking or baking any part of the marijuana plant. </p>
<p>THC mimics a naturally occurring neurotransmitter called <a href="https://pubchem.ncbi.nlm.nih.gov/compound/Anandamide">anandamide</a> that works as a signaling molecule in the brain. Anandamide attaches to proteins in the brain called cannabinoid receptors, which then send signals related to pleasure, memory, thinking, perception and coordination, to name a few. THC works by hijacking these natural cannabinoid receptors, triggering a profound high.</p>
<p>Tetrahydrocannabivarinic acid, another cannabinoid, can constitute up to 10 percent of the dry weight. It is converted to another compound that probably contributes to a high, <a href="https://pubchem.ncbi.nlm.nih.gov/compound/tetrahydrocannabivarin">tetrahydrocannabivarin</a>, when smoked or ingested in baked goods. Potent varieties like Doug’s Varin and Tangie may contain even higher concentrations. </p>
<h2>Medical properties of marijuana</h2>
<p>But not all cannabinoids make you high. Cannabidiol, a cannabinoid similar to THC, and its acid are also present in marijuana, especially in certain varieties. But these do not cause euphoria. The cannabidiol molecule interacts with a variety of receptors – including cannabinoid and serotonin receptors and transient receptor potential cation channels (TRP) – <a href="https://doi.org/10.1016/S1474-4422(15)00379-8">to reduce seizures</a>, combat anxiety and produce other effects. </p>
<p>Marijuana also contains several monoterpenoids – small, aromatic molecules – that have a wide range of activities <a href="https://doi.org/10.3390/ph5101045">including pain</a> and <a href="https://doi.org/10.1016/j.euroneuro.2008.11.004">anxiety relief and that work by inhibiting TRP channels.</a></p>
<p>Myrcene is the most abundant monoterpenoid, a type or terpene, in marijuana. It <a href="https://www.ncbi.nlm.nih.gov/pubmed/12587690">can relax muscles</a>. Other terpenes such as pinene, linalool, limonene and the sesquiterpene, beta-caryophyllene are <a href="https://www.mdpi.com/1424-8247/5/10/1045">pain relievers, especially when applied directly to the skin</a> as a liniment. Some of these terpenes may add to the high when marijuana is smoked.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=540&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=540&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263499/original/file-20190312-86717-znslz3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=540&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Depending on the medical condition, oils or lotions made from cannabis may be a better choice.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/healthy-cannabis-hemp-natural-products-medical-1123351781">sangriana/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>What do all these varieties do?</h2>
<p>Many different varieties of marijuana are on the market and are alleged to treat a range of diseases. The FDA has no oversight for these claims, since the FDA does not recognize marijuana as a legal product. </p>
<p>Strains of marijuana are grown that produce more THC than cannadidiol or vice versa. Other varieties have abundant monoterpenoids. How do you know that the strain you choose is legitimate with probable medical benefits? Each strain should <a href="https://b2b.gocaliva.com/what-is-cannabis-certificate-of-analysis-coa-california/">have a certificate of analysis</a> that shows you how much of each active compound is present in the product you buy. Many states have a bureau of cannabis control that verifies these certificates of analysis. However, many certificates of analysis do not show the monoterpenoids present in the marijuana. The analysis of monoterpenoids is difficult since they evaporate from the plant material. If you are looking for a strain high in myrcene or linalool, ask for proof. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=732&fit=crop&dpr=1 600w, https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=732&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=732&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=919&fit=crop&dpr=1 754w, https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=919&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/263764/original/file-20190313-123554-12w51i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=919&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Certificate of analysis.</span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Marijuana can improve several conditions, but it can also make others worse and can have nasty side effects. </p>
<p>As recreational use has become more widespread, <a href="http://doi.org/10.14309/crj.2018.3">marijuana hyperemesis syndrome</a> is becoming more of a problem in our society. Some people vomit uncontrollably after smoking marijuana regularly. It can be <a href="https://www.ncbi.nlm.nih.gov/pubmed/28494183">treated</a> by rubbing a cream made from capsaicin, from chili peppers, on the abdomen. Capsaicin cream is available in pharmacies. </p>
<p>Also, high THC varieties of marijuana, such as Royal Gorilla and Fat Banana, can <a href="http://doi.org/10.4088/JCP.17r11839">cause anxiety and even psychosis</a> in some people.</p>
<p>Researchers have also shown that anxiety can be effectively treated with strains that have more cannabidiol and linalool. It may be best to <a href="https://doi.org/10.1017/S2045796018000239">rub a cannabidiol balm or lotion on your cheeks to relieve anxiety</a>. </p>
<p>Other conditions that studies have shown are improved by marijuana are: <a href="http://doi.org/10.2217/fon-2018-0530">cancer induced nausea</a>, <a href="http://doi.org/10.2337/dc12-2303">Type 2 diabetes</a>, <a href="https://doi.org/10.1016/S1474-4422(15)00379-8">two forms of epilepsy</a>, <a href="http://doi.org/10.1001/jama.2015.6358">HIV-induced weight gain</a>, <a href="http://doi.org/10.1089/can.2016.0009">irritable bowel syndrome</a>, <a href="http://doi.org/10.1002/phar.1673">migraines</a>, <a href="http://doi.org/10.1517/14712598.2012.721765">multiple sclerosis</a>, <a href="http://doi.org/10.1111/1756-185X.13146">osteoarthritis</a>, <a href="http://doi.org/10.1093/rheumatology/kei183">rheumatoid arthritis</a>, <a href="http://doi.org/10.1001/jama.2015.6358">pain</a>, <a href="http://doi.org/10.1001/jama.2015.6358">chronic pain</a>, <a href="http://doi.org/10.1007/s40261-014-0212-3">post-traumatic stress disorder</a>, <a href="http://doi.org/10.1001/jama.2015.6358">sleep disorders</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/25264643">traumatic brain injury</a>. </p>
<p>For some of these conditions, studies show that eating or topically applying marijuana products rather than smoking is recommended. </p>
<p>Clearly, more research is needed from the scientific community to help guide the appropriate, safe use of marijuana. However, the FDA does not recognize the use of medical marijuana. This makes funding for research on marijuana difficult to find. Perhaps the cannabis industry should consider funding scientific research on marijuana. But conflicts of interest may become a concern as we have seen with drug company-sponsored studies.</p><img src="https://counter.theconversation.com/content/112935/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>James David Adams does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Marijuana is known for delivering a good high. But the plant’s uses go well beyond the recreational. Marijuana contains a trove of medicinal compounds whose uses we are just now discovering.James David Adams, Associate Professor of Pharmacology and Pharmaceutical Sciences, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.