S1 Episode 9: “Bobble Heads” and Concussions

Dr. Barry Kosofsky explains why children – especially girls – are at greater risk for concussion, and why kids under 14 should never play tackle football and certain other contact sports. Learn how to recognize the signs of concussion, when to go to the ER, and why kids with ADHD or anxiety tend to do worse when they have concussions.

Dr. Stieg: Hello, I’m Dr. Phil Stieg and I’m here today having a conversation with my dear friend, Dr. Barry Kosofsky. Dr. Kosofsky is Professor of Pediatrics and Chief of the Division of Pediatric Neurology at NewYork-Presbyterian Hospital, Weill Cornell Medicine Center, and the director of the Horace W. Goldsmith Foundation Laboratory of Molecular and Developmental Neuroscience. Barry, thanks so much for joining me. The reason I have Dr. Kosofsky here, and forgive me, I’m going to refer to him as Barry from now on, is that he is one of the world’s experts on the management of concussion. Tell us what is a concussion, both what happens to the brain and what do you see?

Dr. Kosofsky: So a concussion is loosely defined as a blow to the head. That in some way alters behavior that’s so vague that it makes it difficult to say who does and does not have a concussion. What we like to say is mild traumatic brain injury. By mild traumatic brain injury. We mean somebody who’s taken a blow to the head and it’s going to cause ongoing symptoms and those symptoms can be in a number of domains. The one we usually think about is headache and somebody who has inducible headache, meaning when they’re physically or mentally active and they induce a headache, they had a concussion, they don’t need a CT scan, they don’t need an MRI, they have a diagnosis. If you’re symptomatic following a blow to the head, you had a concussion.

Dr. Stieg: Moms and dads are worried about their kids. Can you put it in sort of a picture for them? Is there something that happens to the brain cells? Do they get rattled? You know, we don’t have to get real molecular about this, but what goes on?

Dr. Kosofsky: When the brain gets injured, different chemicals leak out of the brain and that leads to some altered symptoms and immediately what we think about is confusion, nausea, vomiting and lethargy. So if your kid gets hit on the sideline or falls down at home, and that’s another interesting point. The age really defines how the hit happens. Less than five year olds. Most of the concussions are just by falling five to 15 it’s often sports and also horsing around and then over 15 a lot of it’s assault and motor vehicle accidents as well as sports. You’re looking for nausea, vomiting and sleepiness.

Dr. Stieg: If you see those things, what should mom and dad or a friend do with their patient? Where should they go?

Dr. Kosofsky: I think the pendulum has swung where now everybody goes to the emergency room, especially if their kids are under the age of five, which is conservative because they can’t really tell you what they’re experiencing. But what we like to say is if you know your child or if your coach knows the athlete, are they different than they were before the hit? And the key is knowing, you know, what is their behavior like? How spontaneous are they? How outgoing are they? You can look at somebody’s eyes and if the elevator’s not going to the top, you get concerned. So the physical signs for a parent is that my child just doesn’t look right, isn’t acting right. For the clinician, what we say is if they’re endorsing dizziness, nausea, vomiting, or sleepiness, we want them to come to the emergency room.

Dr. Stieg: So what about the imaging stuff? Do you think everybody should get a CT scan or an MRI scan? Is it important or not?

Dr. Kosofsky: Absolutely unimportant. And here’s why. The reason we say nausea, vomiting and sleepiness, it is important to bring the child to the emergency room is those are the signs and symptoms of blood in the brain. And then we need your team, the neurosurgeons to intervene. However, in the absence of nausea, repeated vomiting or any kind of sleepiness, it’s really unlikely that there’s anything in the head that warrants a neurosurgeon to intervene. We suggest not doing a CT scan, especially in the little ones where the risk of radiation then feeds forward to an increased risk of cancer. If you make it 24 hours, you never need a CT scan after that and you never need an MRI after that. And the reason is MRIs will not tell me anything I need to know to help treat you and you and I never do tests that have no therapeutic implication. Everybody wants to know I need an MRI, I need to know if I had a concussion. If you’re symptomatic, you had a concussion and there’s no reason to get the MRI.

Dr. Stieg: So now my son or daughter just had what I think is a concussion. They come back, or I see at the sporting event that they’ve got a little bit of a headache. They’re a little bit nauseated. Should I put a pair of sunglasses on him, put them in a dark room. Since you say I don’t need a CT scan, I don’t waste time sitting in an emergency department for eight hours, what should I expect or what should I do?

Dr. Kosofsky: I think calling, for children, the pediatrician is the first line of defense and letting the pediatrician know and they usually want to see the child cause they know the child well. They can do a crude neurologic exam. The key is, in those first 72 hours, you do want to power down, but the field has gotten away from cocooning. It turns out if you leave kids in their rooms, they dwell on their symptoms and they’re more symptomatic, not less. We’re getting to a—

Dr. Stieg: So by cocooning you mean putting them in a dark room and isolating them from the family? Correct. Don’t do it.

Dr. Kosofsky: Don’t do that after three days. So the first three days, yes. Power down, minimize screens, minimize texting, minimize stimulation and I can’t always predict what it’s going to be. Some patients, it sounds, sometimes it’s light, going up and down stairs, but whatever the triggers are, try to avoid them. However, starting on day three to four, start gradually escalating activities as tolerated and with kids I say go to school for the afternoon only see if you tolerate class. Usually it’s copying from the whiteboard or concentrating that induces the headache. If it does, you go to the nurse’s office and you don’t power through it. If you tolerate it, then you spend the full day in class. Always return to school before return to play. For me, the priority is two weeks of full academics without inducing any headaches. Then you can gradually return to play cardio drills, scrimmage, game. If you experience any headaches induced along that pathway towards escalation, like with the academics you back off. So I would say as a parent, be cautious, but encourage your child to gradually increase their activities, monitoring for triggers and avoiding the triggers as best they can.

Dr. Stieg: Tell us a little bit about how children react differently to a concussion than adults.

Dr. Kosofsky: So one of the points I just mentioned is that kids, 30% of kids will not get better after concussion and 20% of adults. It’s the only injury that I know of where kids take longer to heal than adults. We always the orthopedists, always joke: You have a kid with a broken bone, you put the two bones in the same room, they heal. What is it about the developing brain that makes children more vulnerable to ongoing symptoms? There’s a lot of theories and no fact. One of the ideas is that the neck muscles are weaker in children and their heads are a bigger part of their volume, their body volume. So we call kids bobbleheads right? Cause the head’s big.

Dr. Stieg: That’s what you always called me.

Dr. Kosofsky: No, that’s what’s uh — the Met guy on the back of your car. So bobbleheads have big heads, weak necks, and they’re at greater risk. So if you think about the same impact will confer more energy and injury to the brain in a child with a big head and a weak neck than it would in an adult. In a related story, after age 14, girls are at greater risk for symptoms than boys. And it may be that their strap muscles in their neck never develop as fully as in men. Now that’s an idea that’s being tested actually to see whether you can strengthen the neck muscles and it could be protective. But the American Academy of Pediatrics has come out with a recommendation, no tackle football before the age of 14. No heading the ball in soccer before the age of 14 because 14 is the time when most children have gone through puberty and their necks are a little bit stronger. That’s one of the foundations for that recommendation I should mention in soccer, it’s not the heading of the ball. It’s going up for the header and head to head and head to ground injury. That’s what’s the problem and that’s more evident in women than men after puberty.

Dr. Stieg: Thinking about moms and dads watching their kids play the sport then trying to be protective of their child. You’ve been speaking about the mechanism of injury. What should they watch for differently in a girl than they might watch for on a boy?

Dr. Kosofsky: I don’t know that the mechanism of injury is different. Clearly the worst sport is boxing and the second worst sport is football. As was said in the movie Concussion, the brain was not built for football. When you then go away from these helmet sports, which hockey is one of, you get into collision sports like basketball and soccer, they are lower risk, but that’s where women compete. Interestingly, if you follow those players, they accrue structural brain injury over time because there’s rapid acceleration, deceleration, and this injury — we used to think it’s the—

Dr. Stieg: By rapid acceleration, deceleration, you mean the head basically whip lashing?

Dr. Kosofsky: That’s correct. And so that gets back to the weak neck, the head whiplashing, and then what happens is it’s not the direct injury of the brain against the skull, but I think about the skull, not to get technical Phil, it’s like broccoli, there’s a flower and a stalk, and with rapid acceleration deceleration, the flower moves on the stock and those fibers right where the flower meets the stalk gets stretched and those are the ones that mediate balance, they mediate eye movement. And we think that’s really the deep injury, the shearing of the white matter, and that’s why it’s so elusive on brain imaging that it’s not a cortical injury with blood. That’s important in the first hours as we mentioned, but it’s this deeper injury that’s very hard to visualize. Now, advanced MRI methods are starting to pick up on that. They’re saying maybe we can use this as a biomarker of injury, but it’s only in advanced research settings. It’s not your common MRIs that can detect this injury.

Dr. Stieg: Let’s talk a little bit about the concept of prevention. So what do you tell moms and dads or for that matter, any teenager that’s starting to take up football, how do you make sure you can try to maximize avoiding having a concussion?

Dr. Kosofsky: So this is the key. We know sports are very good. Team sports build character, discipline, and we want our kids to be as active as possible. We can make it safer. So I think sports can be proactive at changing rules and making it, you see the NFL has changed the rules with quarterbacks and what kind of hits you’re allowed and no chop blocks and no blocks to the head and you’re not allowed to hit the quarterback in the head at all. So I think we’re getting better. One of the interesting points though is helmets give the football player the false sense of security. They can lead with their head. And in the counterintuitive way, it increased the risk of concussion, not decreased. In Australian rules football. There’s fewer concussions. They don’t wear their helmets, so they don’t lead with their heads. However, when they get a concussion, it’s worse because they’re not wearing a helmet.

Dr. Stieg: Well, that was also shown in downhill skiing, as you recall, that people with helmets took greater risk going down and they had more head injuries.

Dr. Kosofsky: So I think it is dangerous. We talk about, should a soccer player wear headbands? The answer is it doesn’t protect your head, but it reminds you that you’re at risk. It’s like wearing a knee brace when you ski, it doesn’t protect you, but it reminds you you’re at risk for injury

Dr. Stieg: With the increase in children participating in sports and the broad diversity of sports… I mean, you’ve talked a lot about hockey, football, soccer and basketball, but let’s face it, there’s field hockey, there’s horseback riding, skateboarding, bicycling, all of the, this massive number of sports.

Dr. Kosofsky: It’s interesting. The Department of Defense partnered with the National Collegiate Athletic Association, so the NCAA, they now have the Grand Alliance and they’re looking at 20,000 athletes at colleges across the country. If you enroll all your varsity athletes, male and female for every sport and they’re trying to figure out what is the risk for each of these different sports. It turns out wrestling came up much higher than we would have predicted. Women’s lacrosse and field hockey came up much higher than we would have predicted, so there are some surprises there. There are, I think, recommendations that we want to make based on that data, that a wait until you’re older to play some of those sports, the collision sports and the helmet sports in particular and be looking at your body type. Some people aren’t built for football. If you have a thin neck, it may not be the right sport for you. Certain bodies aren’t made for ballet, certain bodies aren’t made for swimming. So I think we want to be smart about picking the right sport and encouraging your child.

Dr. Stieg: I just want to say good luck to that with telling your child to pick their sport.

Dr. Stieg: Recently there’s been a lot of conversation about preexisting issues and the effect that that has on your recovery from a concussion and by preexisting issues or conditions. I’m talking about anxiety, ADHD, sleep disorders, concentration disorders, mood disorders. What’s the latest on that?

Dr. Kosofsky: Absolutely. A hundred percent true. Guidelines were just released about pediatric concussion and they emphasize not only importance of identifying such premorbid factors, meaning pre concussion factors, but focusing treatment on those factors. Anxiety in my clinic, so I run a pediatric concussion clinic here at Cornell, the single biggest factor predicting prolonged symptoms is if somebody was anxious before the concussion to the point where I have a cognitive behavioral therapist in my clinic.

Dr. Stieg: That’s a mouthful. What is a cognitive behavioral therapist?

Dr. Kosofsky: So CBT—

Dr. Stieg: A psychologist, right?

Dr. Kosofsky: It’s a psychologist who specializes in changing cognitions, by which I mean, if you’re anxious and you get a concussion, when you experience this pain, I alluded to that you’re physically or mentally active and you feel headache. The pain controls you instead of you controlling the pain and it spirals out of control and these are the kids that are home for three, six months or out of work or the adults out of work for a year or two. You’ve got to prevent that cycle from developing and to do that, if I get the history, I bring psychologists into the room, they talk about anxiety and they say, “Look, when you feel that pain coming on, deep breathing, relaxation, diaphragmatic breathing 

imagery, you’re in control,” and it’s a game changer.

Dr. Stieg: Be good if we could teach a lot of adults to do that on a regular basis.

Dr. Kosofsky: And it’s a generalizable skill, Phil. Meaning that you learn it now, but you can use it when other stresses occur. So this kind of approach will refer back out to the community. You have a smart kid, seven, eight lessons. They master it. It’s a lifetime skill, but we’re seeing anxiety as the biggest factor predictive of ongoing symptoms, attention deficit disorder, learning disability, also the case. And then the tricky part there is if they’re on stimulants, I want them off of stimulants when they’re recovering. But then they’re having a harder time in school and harder time concentrating.

Dr. Stieg: There’s been a fair amount of literature coming out now about concussion and then suicide risk. I certainly don’t want parents being terrified that, “Oh my God, my child had has one concussion and I’ve gotta be worried about this too.” What’s the latest on that?

Dr. Kosofsky: So this relates to what do you bring to the concussion. As you mentioned, you know, some of it is premorbid anxiety and other psychiatric disorders, those predisposed for prolonged symptoms. What we’re learning now, and this sort of gets to the issue of CTE, chronic traumatic encephalopathy. There’s been a lot of hype about football players like Junior Seau who was highlighted in the movie concussion killing themselves and before they committed suicide, they were aggressive, they were moody, they were irrational and aggressive. That describes a lot of football players before the concussion. So that’s part of the problem. These are aggressive men who get paid to be physical. However, it did turn out that there is something, a new disease that was initially described in boxers — dementia pugilistica that was then evident in football players. Some subset of whom were violent and committed suicide. That is a vanishingly small number of football players.

Dr. Kosofsky: Most people who’ve played football have done very well and we’re trying to figure out what are those factors that are different? One of the factors, interestingly, is when you started playing football, back to our initial discussion. They looked at pro football players and who had neurodegenerative changes, so not as far as suicide, but who had Parkinson’s, who had Alzheimer’s, who had memory problems. If they were pros and started before they were 14 it was an increased risk as opposed to after 14 so presumably they got their heads bashed in equally in the pros, but the early exposure before 14 before that neck gets strong — that puts them at a lifetime risk for dementia. A very small risk. Very few of the football players developed it, but more who played starting before age 14 than after.

Dr. Stieg: So the take-home message for this topic, the suicide and this chronic traumatic encephalopathy, again, is the frequency with which the child as a blow to their head and has a concussive episode. Mom and dad with one concussion shouldn’t be worried about the fact that they’ve left their kid do something terrible and they’re going to be disabled later on in life.

Dr. Kosofsky: Absolutely. Um, and likewise, a lot of these injuries, I’ll take kids, I give them the three strike rule after three strikes. I really don’t want you playing helmet sports and I’d like you to avoid concussion sports, but sometimes the concussions occur just at home or out socially. So you can prevent, you can’t put your kid in a bubble. You can try to minimize risk and get them to make good decisions. But no — three concussions is not going to lead to chronic traumatic encephalopathy. The football players in particular, the alignment of getting sub-concussive blows every play and some of the forces on the backs, running backs, the defensive backs, the linebackers are enormous. So I think that’s a whole different mechanism of brain injury. There’s a whole different neuropathology and we’re learning there’s a genetics to it. And you can’t change your genetics, but it turns out the same gene APOE e4 that predisposes you to dementia and Alzheimer’s predisposes you to more prolonged symptoms after traumatic brain injury.

Dr. Stieg: Over this brief time, we’ve really reviewed the concept of prevention, treatment, and diagnosis and recovery. What are the three or four take home key points that the listeners should know?

Dr. Kosofsky: If there’s a blow to the head, no need to go to the emergency room, do let your internist or your pediatrician know. No need to go to the emergency room unless you’ve got nausea, vomiting, and sleepiness. If you don’t and your symptoms are manageable at home, power down for three days and then gradually increase your activities. If you have inducible headaches, be respectful of those triggers.

Dr. Stieg: What do you mean, inducible?

Dr. Kosofsky: By physical or mental activity. So for kids, if they go to school and they induce headaches, if for adults, if they’re at work and they induce headaches. For athletes, if they work out and induce headaches, I always recommend return, unless you’re a professional athlete, return to school, return to learn before return to play. That’s the priority. And then try to get as much rest and be respectful of the headache and not power through the headache and the whole syndrome will get resolved faster.

Dr. Stieg: And the longterm prognosis for this is excellent, correct?

Dr. Kosofsky: Excellent. 80% of the adults, 70% within two weeks, and I’d say 90% will get better. Long term, it’s that 10% we’re trying to pick up early and get them the appropriate therapy. Anxiety is the gorilla in the room. If your child is anxious, you’ve got to get on top of that quickly. Or if you have personal anxiety. And the problem is anxiety is rampant in our society and it’s contagious. So what you’ve got to do is think about these psychologic approaches, these nonpharmacologic interventions: relaxing, yoga, meditating. I tell my patients to swim. Swimming is great because there’s not a contact sport. It’s individual to have neck problems. I should mention one last point. Sometimes the neck can be injured and it’s often overlooked. So if there’s neck pain, physical therapist. If you’re having trouble visual tracking, visual therapist. If you having trouble with your balance, vestibular therapist. But the key to this is if you’re anxious going to the psychologist for cognitive behavioral therapy, triaging patients at risk for ongoing symptoms, the appropriate treatment will take care of the other 10% that don’t get better on their own.

Dr. Stieg: Dr. Barry Kosofsky, thank you for this most scintillating conversation and your analysis of the management of concussion or a mild traumatic brain injury.

Dr. Kosofsky: Thank you, Phil. I appreciate the opportunity.