I was recently asked to see a 14-year-old boy who had suffered a head injury playing lacrosse. A year ago, immediately after scoring a goal, he was knocked to the ground by the other team’s defenseman. His teammates pulled him to his feet, patting his back with congratulations. But it was clear he was not right—he was confused, not sure of the score, and quite wobbly on his feet. He did not play further in that game, but by mid-week said he was back to normal. He played in the next game, the final game of the season, and then played in a summer league.
Last fall, he switched to soccer. While fooling around during practice in November, he didn’t see the ball coming, and it crashed into his head, knocking him to the ground. This time he didn’t come around right away. He felt nauseous, had a headache that night, and couldn’t concentrate in school the next day. These symptoms have persisted. It is now the end of April, and he has essentially lost a full school year. Any exertion gives him headaches. Some days he is sharp as ever in school (where he has consistently been an excellent student), other days he just seems to be in a daze. He sometimes has sleepless nights and then dozes off in class the next day. What is going on here?
This lad has post-concussion syndrome.
Let’s consider how we (that is, parents and physicians) would have handled this problem 10 years ago, how we handle it now, and how we might handle it 10 years in the future.
Ten years ago, the problem would have been essentially ignored. At the time of the first injury, a few questions would be asked, such as, “Who are you playing? What’s the score? Are you all right?” Often the player stayed in the game, even though he was not sure where he was. The idea that he might be setting himself up for further injury wasn’t considered. This was a combined effort of players (who would hide their injuries or symptoms in order to compete), coaches (who wanted their best players on the field), and parents (who didn’t know any better).
Now, the ill effects of repeated head injuries are recognized. There is a desire to have a person recover to his pre-head injury level before continuing competition and we understand the benefit of giving a person psychological support during the recovery phase. On the other hand, the situation has been complicated by the concept of PTSD (post-traumatic stress disorder), which has often been diagnosed in soldiers who suffered head injuries from the strong concussive waves from a roadside bomb, as often occurred in Iraq. Here the head injury is superimposed on the stress of military deployment in a very stressful environment. Much of the discussion—too much in my estimate—has focused on the psychological aspects of PTSD. But a recent article in The New York Times by Nicholas Kristof, “Veterans and Brain Disease,” focuses on the physical. He reports that an autopsy of a 27-year-old soldier with PTSD showed damage similar to what is found in football players years after they have stopped playing: chronic traumatic encephalopathy or CTE. In this condition there is a very unique pathology with the accumulation of the protein tau, a component of the tangles found in Alzheimer’s disease.
In the future, say 10 years from now, several changes in our thinking will have taken place. Not all people get these chronic symptoms. Are there risk factor genes that make it more likely to have this adverse response? My guess is that there are.
The pathology of CTE suggests that the bad actor is tau—the toxic protein that kills nerve cells. We can’t yet detect this protein by imaging, but many scientists are trying. Let’s say we could. In that case, we would put my patient in a scanner and see if tau has started to accumulate. The ability to do that would have enormous effect. I would tell his parents, and football players, and Iraq veterans, that they are accumulating a substance in their brains—that this is not a basic psychological problem.
Now what? If we are going to speculate, let’s go all the way. How are we going to treat these people? We have to find a way to stop this accumulation of tau, and to rid the brain of it. Currently we don’t know how to do that, but we will.
Putting this all together, I will be able to tell the parents of my patient whether their son is at greater genetic risk for the long-term ill effects of head injury and I will be able to give him some preventive medications.
Science fiction with a dose of reality!