A blog entry about football-induced brain injury.

There is a problem when it comes to the issue of football and brain injury....

The people that know about football know nothing about the brain, and the people who know about the brain know nothing about football.

I know a little bit about both. Here's my 2¢:

I played football all through high school from freshman to senior. During my sophomore year, I never left the field. Kickoff, kickoff return, punt, punt return, every play on offense, every play on defense. I played pretty much every position on the field from nose tackle to linebacker and defensive back to quarterback to receiver.

Are you interested in having your kids play football? Are you wondering if the years you played may have left a residual affect on your brain? Here are a few things that you should know:
 

Other sports have head injuries. A lot of the popular press points this out. They say "Well, you hit your head in soccer when you head the ball." "When you play hockey you can get checked, that can cause a head injury." Of course they're both true. You could potentially have a head injury in almost any sport. Absolutely. No question. You could hit your head a few times a game.

What most folks don't realize is that in football you hit your head on almost every play. You are either blocking someone, trying to run over someone or falling. When you fall in football it is not a controlled fall. There's a variety of forces -usually other peoples bodies-- that impact the trajectory of your fall. All control is gone. Also, a lot of the time your hands are full, usually with somebody else's jersey.

As you fall your head hits the ground. It may hit many other things on the way to the ground, but it will almost always hit at the ground. When your head hits the ground the skull stops, but the brain keeps going. In fact, during any hit to the head in football, the brain keeps going...

And because the brain keeps going players cannot be protected by any kind of helmet. This is because, once again, the head will stop, the skull will stop, but because the brain is in fluid (cerebrospinal fluid) the brain will keep going. And you might think, who cares? So it keeps going but the skull is really smooth and so it hits a smooth area and it kind of sloshes around a little bit. So what? The impact wouldn't be significant enough to damage the brain. This is where a pretty intimate knowledge about the anatomy of the skull is important. People think of the skull they think of a really smooth surface. In fact, only the top half of the skull is smooth.

The bottom half is so convoluted and has pieces that are so sharp, that if you pressed your hand into it with a few pounds of force, you would  open the skin. So as the brain continues to move forward it is scraped against these many sharp edges that stick up into the bottom of the brain. And because there is a head hit in every play (okay not every play, you may be a decoy and not have to hit anybody. But for most positions almost play the head will get hit. I played QB for a year. I took the worst hits that year) the brain will be scraping every time. There is no good data on what this does to the brain. Everybody is focused on concussions, but because this ("scraping)" is done over and over and over to the brain, it may actually be more damaging in the long term.

So how many hits do high school player take to the head?

A high school football player may take anywhere from 200 to 1,800 hits to the head during the course of a single season. 

So if you think your precious game is above the organ that most makes us human, you can pretty much kiss my...... 

Spasticity After Stroke III: Options for Treatment

      What else works? BOTOX® (botulinum toxin type A) can be injected directly into the spastic muscles to provide months of spasticity relief. Intrathecal baclofen (ITB) therapy delivers spasticity medication to the intrathecal space (fluid flows around the spinal cord) corresponding to the spinal level of the spastic muscles. Oral medication, dorsal root rhizotomy, orthopedic surgeries and other treatments do reduce spasticity. And if you think that these medical interventions have nothing to do with therapists, think again. Physiatrists and neurologists believe that spasticity that limits function is one of the triggers for appointments for these experts in spasticity reduction. Who better than therapists to gently guide patients to these doctors for spasticity treatment?    
        A word of caution here: Once directed to a doctor who specializes in spasticity interventions, patients sometimes forget what to say and end up saying something vague like, "I want to move better." Prior to sending patients with spasticity to these doctors, tell them in clear and concise terms exactly what muscles you want the doctor to work on. If the patient has trouble with dorsiflexion because of spastic triceps surae, having the doctor BOTOX® the finger flexors is not going to help.
       The Holy Grail for spasticity reduction is a melding of doctor-prescribed medical interventions and therapist-delivered neuroplastic treatment options. The proper mix of these interventions is emerging as research goes forward. Guiding patients back to neurology and physiatry and accepting neuroplasticity as the substrate for authentic spasticity reduction are good first steps.

Spasticity I: The "Magic" "Cure" for Spasticity Reduction?

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Why do I have spasticity? What can I do to get rid of spasticity? When will it go away?"

        People who have any number of pathologies can suffer from spasticity. Spinal cord injury, multiple sclerosis, amyotrophic lateral sclerosis (Lou Gehrig's disease) and other pathologies have spasticity as a sequela. This column will discuss spasticity as it relates to acquired brain injury which includes traumatic brain injury, cerebral palsy and stroke.

     Most clinicians provide patients with overly simplified, incomplete and often inaccurate information about what spasticity is, its etiology and its cure. Therapists generally believe that patients don't want detailed explanations. But patients need to understand their spasticity. Why? Having patients understand their spasticity is essential because spasticity will only reduce if executive control over the spastic muscles, by the brain, is restored. And executive control over muscles will only happen with repeated firing of the muscle in question, and repeated firing will only happen if the patient wants it to happen.

Stop the therapy cap!

Addendum 9.18.14: 
As of today 220 members of the 435 congressmen have signed on as co-sponsors of the House bill to repeal the therapy caps. --Thank you Rebecca Dutton!

Let's say you've had a stroke. Not much of a stretch, huh? Now imagine a federal algorithm that determines the amount of therapy you'll get before you even have a stroke. Can't be done you say? Every stroke is different and so would need a different amount of therapy. 

You'd think the amount of therapy you'd get would be based on what the clinicians sitting in front of you think you need. But yeah, no. That's not the way its done. 

For stroke survivors the amount of rehabilitation available has progressively fallen as subacute stroke inpatient stays have dropped to an average of less than 16 days and as Medicare has capped the number of outpatient therapy sessions to 15/year.

And what really confuses me is why the Federal guidelines are not in concert with what the research says! 

So, if you're with me on this, click the red image above and let 'er rip. 

PS, the congressman who had a stroke, how much therapy did he get given the insurance provided congress? "...nearly a year of intense, grueling physical and occupational therapy." 

Exercising the Brain after Stroke

What drives stroke recovery? This question is both complicated and profoundly simple. It’s complicated because recovery involves rewiring the brain, and the brain is...complicated. It’s simple because the brain rewires in response to very simple instructions. In fact, these instructions have been known to athletes, musicians and other skilled workers for thousands of years. 

In the rehab clinic, exercises are called "thera ex (short for therapeutic exercise).

Therapists usually want to know which are the best thera ex for helping stroke survivors recover.       Beyond exercising, the other big option used in clinics are collectively called handling techniques. Handling techniques are just like they sound, the therapist moves you. Handling techniques, if you believe the research, don't much help. (If they did, I'd pay someone to "handle me" into being a better skier!). Exercise, for its part, is great! Exercise makes the muscles that need strengthening, stronger. The problem is, exercise is only mildly effective at changing the brain-- and stroke is a brain injury. Let me put it this way: a muscle can be strong, but useless because it does not know what to do. "Muscle memory" does not exist. The brain controls while muscles can only do two things: contract and relax. It's the brain stupid. 

Consider the one stroke recovery option that has consistently done really well in research, constraint induced therapy (CIT). In CIT, there are no specific exercises. Movement is required, however. The movements required during CIT very little resemble thera ex because focus is on repetitive practice, not muscle strengthening. And there are no handling techniques. In fact, CIT is decidedly and pointedly hands-off. It is cause of some curiosity among researchers why this hands-off philosophy is so difficult for therapists to accept. The only way of driving cortical change towards recovery is through volitional efforts by the stroke survivor. These efforts are actively encouraged no matter how ugly, synergistic or uncoordinated they are. Edward Taub, the person who developed CIT is a psychologist. As he was developing CIT in animal models, handling techniques and exrcises may have been the furthest thing from his mind. The closest, certainly, was operant conditioning which does appear to change the brain. Stroke is a brain injury, not a problem specific to muscle weakness. The term “neuromuscular re-education” is used a lot in PT and OT. In fact, you can bill for it. But the term is a misnomer. If it was an honest term it would be "motor-cortical reduction", or "movement reeducation." Relearning how to move after stroke has little to do with the muscles and everything to do with the brain. Stroke recovery involves brain reeducation. Different focus, different organ, different paradigm, different rules, different outcome measures.