Monthly Archives: November 2012

Does Playing Soccer Change the Brain?

White-matter integrity alterations seen in 12 soccer pros, even in the absence of symptomatic concussion
By TIM SULLIVAN 
November 26, 2012
Soccer is one of the world’s most popular sports. It is also the only sport where the head, unprotected, is a primary point of contact for the ball when playing. In other contact sports, the negative effects of repetitive traumatic brain injury are well recognized; however, the effects of frequent blows to the head below the threshold of concussion, as seen in soccer players, remains controversial.
In the first study to show alterations in white matter in professional soccer players, HMS researchers and colleagues at Ludwig-Maximilians-University in Munich investigated the brains of 12 soccer players using high-resolution diffusion tensor imaging to investigate structural changes in the brain, specifically white-matter architecture. White matter is the communication network responsible for communicating messages between neurons (gray matter) in the brain.
This research was published in a letter in the Journal of the American Medical Association on Nov. 14.
“Our study found differences in integrity of the white matter of the brains of soccer players compared with swimmers,” said Inga Katharina Koerte, lead author and a visiting research fellow in thePsychiatry Neuroimaging Laboratory at Brigham and Women’s Hospital. “Although only participants without previous symptomatic self-reported concussion or physician-diagnosed concussion were included, we found changes in the brain that are consistent with findings observed in patients with mild traumatic brain injury.”
Researchers evaluated 12 right-handed male soccer players from elite soccer clubs in Germany and compared them to eight swimmers, a sport with low exposure to repetitive brain trauma, from competitive clubs. Aside from their professional sport, the groups were otherwise similar in age, handedness and gender.
In this study, conventional magnetic resonance images used routinely in clinical settings showed no abnormalities when read by a neuroradiologist, suggesting the importance of using more sensitive measures to detect subtle changes in the brain. Researchers then employed high-resolution diffusion tensor imaging, and observed widespread differences between the 12 soccer players and the eight swimmers.
High-resolution diffusion tensor imaging non-invasively provides information about the diffusion of water molecules in biological tissue and can therefore reveal microscopic details about tissue architecture. In the brain’s white matter, diffusion of water molecules reflects the coherence, organization and density of fibers, which makes this imaging technique highly sensitive to changes in white matter architecture.
The alterations were observed in the white matter of the frontal, temporal and occipital lobes in the soccer players when compared to the swimmers. These regions of the brain are known to be responsible for attention, visual processing, higher order thinking and memory.
“The origin of these results is not clear. One explanation may be the effect of frequent subconcussive brain trauma, although differences in head injury rates, sudden accelerations, or even lifestyle could contribute,” said Martha Shenton, senior author and professor of psychology and radiology at Brigham and Women’s and a researcher at the VA Boston Healthcare System. “Additional research is needed to confirm these results we observed in this small sample of soccer players and to help clarify the effects that alterations of white matter have on behavior and health.”
Co-authors, including Ross Zafonte, vice president of medical affairs at Spaulding Rehabilitation Network, echo the importance of following up on this finding as key to understanding the meaning of the changes observed in this group of athletes.
This research was funded by the Else Kröner-Fresenius-Stiftung, Germany (IKK) and the Deutsche Akademischer Austauschdienst (IKK). This work was also supported in part by the INTRuST Posttraumatic Stress Disorder and Traumatic Brain Injury Clinical Consortium funded by the Department of Defense Psychological Health/Traumatic Brain Injury Research Program (X81XWH-07-CC-CS-DoD; RZ, MES), and by an NIH NINDS funded R01 (R01 NS 078337 MES
This story was adapted from a Spaulding Rehabilitation Hospital news release.

Ransom’s Goldstein has made an Impact – Miami Herald

The Miami Herald

Ransom’s Goldstein has made an impact

BY WALTER VILLA
Special to The Miami Herald

After suffering from a few concussions, David Goldstein of Ransom Everglades wears headgear for protection during soccer games on November 14, 2012.

A 25-yard header is rare, but even more so when the player who hit it is a high school senior who has suffered three concussions and is only a couple of years removed from thinking he would never play soccer again.Ransom Everglades defender David Goldstein, who plays with a rugby helmet for protection, scored the far-out header last Friday, catching the University School goalie off his line and snapping a 1-1 tie in the 65th minute of a 3-1 win.

“He just powered that ball,” Ransom coach Dave Villano said.

Goldstein’s real power, though, is what he can do with what’s inside his head.

A straight-A student who has applied to Princeton University, Goldstein helped the Florida legislature pass a law — senate bill 256 — that sets guidelines for the treatment of Florida youth athletes with head injuries.

After the bill became law, Gov. Rick Scott came to Miami last month and met with Goldstein before performing the ceremonial signing.

Goldstein also raised $35,000 to provide ImPACT baseline concussion testing for all athletes at Miami-Dade County public schools. Once an athlete suffers a blow to the head, his post-injury tests are compared to his baseline, or pre-injury, exams.

“David singlehandedly made sure that every athlete in our county can be ImPACT tested,” said GMAC instructional supervisor Cheryl Golden, who added that Ransom has committed to perpetuating the fund, spending roughly $7,000 per year to test all incoming freshman athletes in the county.

Goldstein’s history with brain trauma began while playing soccer in the sixth grade, when he was hit in the head with a booted ball at close range. A head-to-head collision in the eighth grade became his second concussion.

His third happened as a freshman at Ransom, playing a district final against Gulliver. Goldstein had already gotten rid of the ball when a Gulliver senior crashed into his head violently.

“You can see on the game tape that instantly my hands went to my head,” Goldstein said. “But I didn’t realize the severity of the injury at the time. Now, I know I should’ve come out of the game right away.

“I’m lucky I didn’t get hit again. When a youth athlete gets a concussion and isn’t removed from play and then gets another blow to the head, that’s second-impact syndrome. There’s a potential of brain damage and even death.”

Goldstein’s symptoms persisted for nearly four months, and it got so bad that he would often have to take naps at the nurse’s office during school hours.

Several doctors told Goldstein there was nothing they could do to help, but that changed when he visited with the team at University of Miami Sports Medicine.

“They told me that a lot of my problems were caused by a balance issue and that there was medicine that could help me,” Goldstein said. “They told me I could play soccer again if I took the proper precautions.”

Inspired by his doctors, Goldstein decided to make sure that other young athletes don’t go through a similar ordeal.

After raising the money to fund the baseline tests in Miami, Goldstein was contacted by the Florida Brain Injury Association. They wanted him to join their effort to increase brain injury awareness and protection.

Goldstein made several trips to Tallahassee to speak to state legislators. The bill met opposition, however, and was defeated in May of 2011.

Undaunted, Goldstein and his cohorts came right back. Earlier this spring, Goldstein found himself in front of the Senate Health Regulation Committee, engaged in a debate of sorts.

“Here’s this 17-year-old,” Goldstein said of himself, “going up against this long-time senator [Dennis Jones, 71].

“I wouldn’t say I was responsible [for the passing of the bill], but it exemplified that we were ready this time. We weren’t going to get outmaneuvered, and it ended up passing unanimously.”

Since the passing of the bill, student-athletes who want to play high school sports in Miami-Dade County must sign consent forms designed to educate them on concussions.

If an athlete is under suspicion of having a head injury, they must be removed from play, and they cannot return until a medical doctor clears them.

“This puts injured athletes in the proper hands,” Goldstein said.

Goldstein himself returned for his sophomore and junior seasons and is now a team captain.

“David’s a very good high school soccer player,” Villano said. “He’s not sure yet whether he will play college soccer, but he is an indomitable competitor. With his ability to inspire and organize, he is one of the best captains I’ve ever had.”

Villano said Goldstein’s impact will be felt long after he graduates from Ransom.

“In the old days, we as coaches had no awareness of what to look for in regards to a concussion,” Villano said. “We’d just ask a kid, ‘How many fingers?,’ and if he guessed right, they were right back on the field.

“Now we have a lot better idea of what to look for, thanks to David.”

For more information, please visit countywideconcussioncare.com

Athletes feeling impact of new concussion policies

Football players undergo baseline testing and evaluation before resuming play

November 14, 2012
By Christy Cabrera Chirinos, Sun Sentinel

Cooper City football player Tyler Sabine took a brutal hit in a game early this season. The sophomore was throwing up just before halftime. His coaches knew it was time to pull the linebacker from the game.

Two days later, Sabine was diagnosed with a concussion.

That diagnosis kicked into place new guidelines passed by the Florida Legislature eight months ago, establishing strict procedures to allow concussed athletes, such as Sabine, back on the field.

As the high school and youth football seasons wrap up this month, many say the new law on concussion management is working.

Sabine was sidelined for more than two weeks before doctors cleared him to begin the gradual four-step return-to-play protocol now mandated by the Florida High School Athletic Association.

“Our trainers were amazing once they realized there was an issue,” said April Bourassa, Sabine’smother. “It was scary. It’s a brain injury, and it’s not like you have another one of those. But they’ve really made it to where now, you’re more informed and I love that. Everyone was very thorough. I felt like my son was being taken care of and informed.”

High school coaches and parents are being more hands-on about concussion awareness. Injured athletes are being evaluated by physicians, and sitting out as long as needed. Once medical clearance is given for them to return, athletic trainers are helping those athletes follow state guidelines that gradually manage a safe return to play.

“This is something that had to be dealt with,” said Archbishop McCarthy coach Byron Walker, who has seen one of his players, running back Nick Bost, sidelined with a concussion this season. “It takes it out of the hands of people who have an interest and puts it in the hands of professionals. It’s just going to be safe for the kids in the end.”

Bost, who was injured during spring practice, only recently returned to action after dealing with post-concussion syndrome months after his concussion.

“I knew it had to be done,” Bost said. “It may have been a mild concussion, but I wanted to be cautious and because I was still having symptoms, I held myself out. And my coaches were cool about it. They understood.”

Returning to action

The new law requires that if an athletic trainer or coach suspects an athlete has suffered a concussion, the athlete must be removed from play. And once an athlete has been diagnosed with a concussion, he or she cannot return to play until medically cleared by a physician.

Once that clearance is given, state policy dictates an athletic trainer supervises a four-step return-to-play protocol in which athletes see their activity level increase daily. If at any point in the process, an athlete exhibits concussion symptoms such as dizziness or sensitivity to light, they must wait at least 24 hours before attempting that level of activity again.

Youth football leagues across South Florida also are working to keep the youngest football players safe. Ross Sinel, president of the American Youth Football League, which includes teams from Broward, Palm Beach and Miami-Dade counties, said educating coaches and parents has been a major part of the league’s concussion management efforts.

And like high school athletes, no concussed AYFL athlete can return to play without a physician’s clearance.

“We had a clinic for our coaches with the doctors from the University of Miami, we have a policy where all coaches and parents have to sign off on concussion documents, and the AYFL has kept a database of all the concussed kids,” Sinel said.

In addition to the new state law which went into effect July 1, Broward County Schools have mandated baseline concussion testing for all high school athletes.

In Palm Beach County, more than 600 football players have participated in voluntary baseline testing.

All of that has helped lead to increased education and awareness of an often-misunderstood injury that if not treated properly, could have lasting effects on young brains.

“I think it’s all helping people do their jobs more effectively,” said Stephen Russo, the director of Sports Psychology at the Nova Southeastern University Sports Medicine Clinic. “The athletic trainers are overseeing the return-to-play protocol, the doctor is doing the medical approval, I’m doing what I’m trained to do and the coaches, at the end of the day, are doing what they’re trained to do. Everyone has their assigned roles in helping the athletes.”

Russo is working with the Broward County Athletic Association to carry out its baseline testing program. He estimates that this year, more than 50 athletes already have come to Nova’s Sports Medicine Clinic for post-concussion evaluation. In the entirety of the 2011-2012 school year, the clinic saw 101 cases.

At Cleveland Clinic in West Palm Beach where Dr. Evan Peck is helping Palm Beach County schools carry out its voluntary testing, there’s been an increase in patients, too.

Persistent differences in patterns of brain activation after sports-related concussion: A longitudinal fMRI study

A. Dettwiler, M. Murugavel, M. Putukian, R. Echemendia, V. Cubon, J. Furtado, D. Osherson
Princeton Neuroscience Institute, Princeton University
Department of Psychology, Princeton University, NJ

Avoiding recurrent injury in sports related concussion (SRC) requires understanding the neural mechanisms involved in recovery.Prior studies have reported functional differences of brain activation in athletes with SRC. fMRI studies using working memory tasks suggest altered patterns of activation in the dorsolateral prefrontal cortex. Chen et al. (2004) reported fewer task-related activations and significantly decreased BOLD signal changes in the DLPFC in athletes with persistent symptoms compared to normal controls. Differences in brain activation in response to varying degrees of working memory processing load (N-back: 0, 1, 2 and 3 back) were identified by McAllister et al. (1999) in subjects with mTBI (Glasgow score 13-15) within one month after injury. The primary purpose of this study was to define neural correlates of SRC during the 2 month following injury, using a working memory task and fMRI.

View Research

Soccer Players Show Signs of Brain Damage

 

Soccer Players Show Signs of Brain Damage

By Todd Neale, Senior Staff Writer, MedPage Today

Published: November 13, 2012
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
(Click link “Med Page Today” below to view video)

 

 

Repetitive hits on the head that are below the threshold for causing a concussion may still result in changes in the brain’s white matter, a small study of soccer players suggested.

On average, elite male soccer players — who often use their heads to direct the ball — had a range of negative changes in white matter architecture compared with a group of competitive swimmers who were unlikely to have repetitive brain trauma, according to Inga Koerte, MD, of Harvard Medical Schools Psychiatry Neuroimaging Laboratory in Boston, and colleagues.

Those differences were observed even though none of the participants in either group had a history of concussion, Koerte and colleagues reported in a research letter in the Nov. 14 issue of the Journal of the American Medical Association.

Although it is possible that frequent heading of the ball could explain the impairments in the soccer players, “differences in head injury rates, sudden accelerations, or even lifestyle could contribute,” the authors wrote.

Previous studies have shown that repetitive traumatic brain injury can have negative long-term consequences — including impaired white matter integrity — but the effects of frequent subconcussive head impacts are less clear.

Koerte and colleagues explored the issue using high-resolution diffusion tensor imaging, which can detect changes in white matter architecture.

The study included 12 right-handed male soccer players from an elite-level soccer club in Germany. All had trained since childhood for a professional career. Their mean age was 19.7 and they had been playing for an average of more than 13 years.

The control group consisted of 11 competitive swimmers who were matched by age, handedness, and sex. Their mean age was 21.4 and they had trained for an average of more than 9 years.

None of the participants in either group had a history of concussion or any neuropsychiatric disorders.

All underwent diffusion tensor imaging to measure markers of mild traumatic brain injury (fractional anisotropy and mean diffusivity) and axonal and myelin pathology (axial and radial diffusivity).

After adjustment for age and years of training, the soccer players showed increased radial diffusivity “in the right orbitofrontal white matter, the genu and anterior portions of the corpus callosum, association fibers involving bilateral inferior fronto-occipital fasciculus, bilateral optic radiation, and bilateral anterior cingulum, right anterior, right superior, and bilateral posterior corona radiata, right anterior limb of the internal capsule, right external capsule, and right superior frontal gyrus” (P<0.05 for all).

A widespread increase in radial diffusivity also has been seen in patients with mild traumatic brain injury and suggests possible demyelination, according to the researchers.

Soccer players also had higher axial diffusivity in the corpus callosum, but there were no differences between the groups in fractional anisotropy or mean diffusivity.

A neuroradiologist found no abnormalities in structural images of the brain.

The researchers could not exclude the possibility that heading the soccer ball resulted in the changes in white matter architecture, but they said that the reason remains unclear.

As an alternate explanation, they noted that “soccer players showed increased axial diffusivity in the absence of increased radial diffusivity limited to the corpus callosum, possibly resulting from specialized training or neuroinflammation.”

The authors acknowledged that the study was limited by the small sample size, the use of a single cross-sectional evaluation, and the lack of information on functional outcomes.

The study was supported by the Else Kröner-Fresenius Stiftung and the Deutsche Akademischer Austauschdienst. It was also supported in part by the Intrust Post-traumatic Stress Disorder and Traumatic Brain Injury Clinical Consortium, which is funded by a Department of Defense Psychological Health/Traumatic Brain Injury Research Program grant, and by a grant from the National Institute of Neurological Disorders and Stroke.

Koerte reported receiving a fellowship from the German Academic Exchange Service and Else Kröner- Fresenius Stiftung; having a grant pending with the NIH; and receiving travel expenses and accommodations from the Society for Neuropediatrics in Germany. Her co-authors reported relationships with Springer Publishing, Bracco, Philips Radiology, Munich Medical International, Deutsches Zentrum fuer Neurodegenerative Erkrankungen, Friedrich-Baur Stiftung, Arbeitsgemeinschaft Botulinumtoxin, Deutsche Forschungsgemeinschaft, Omnibus Stiftung, Guerbet, Merck-Serono, the Radiological Society of North America, Philips, Siemens, Deutsche Roentgengesellschaft, Alfried-Krupp-Stiftung, Bayer-Schering, Thieme Medical Publishers, the European Society of Radiology, Asklepios Clinics, Eurobioimaging, the German National Cohort, Munich Cluster of Excellence M4 Imaging, BMBG German Centers for Lung Diseases and Cardiovascular Diseases, the NIH, the Department of Defense, the International Brain Injury Association, Demos Books, Elsevier, Intrust, the U.S. Department of Veteran Affairs, the National Alliance for Medical Imaging, the National Institute of Mental Health, National Alliance for Research in Schizophrenia and Depression, Fogarty International Center, National Health and Medical Research Council, Silvio Conte Centers for Basic Translational Mental Health Research, and the 9th World Congress on Brain Injury.