Tag Archives: TBI
Researchers from The Ohio State University have announced they have discovered how blows to the head cause numerous small swellings along the length of neuronal axons. The study, “Polarity of varicosity initiation in central neuron mechanosensation,” which will be published June 12 in The Journal of Cell Biology, observes the swelling process in live cultured neurons and could lead to new ways of limiting the symptoms associated with concussive brain injuries.
Mild traumatic brain injuries, or concussions, cause a variety of temporary symptoms, including headache, nausea, and memory loss. But the effects of concussive impacts on neurons in the brain are poorly understood. One such effect is the development of “axonal varicosities,” small, bead-like swellings that appear along the length of neuronal axons, which are the parts of neurons that transmit electrical and chemical signals to neighboring nerve cells. Similar swellings are seen in the degenerating axons of Alzheimer’s and Parkinson’s patients.
Chen Gu and colleagues at The Ohio State University discovered that they could induce the formation of axonal varicosities in hippocampal neurons grown in the lab by “puffing” them with bursts of liquid from a small pipette. The pressure exerted by these puffs was similar to the forces neurons might experience after a blow to the head.
The axonal varicosities formed rapidly, particularly in younger neurons where they swelled up within 5 seconds of being puffed. A surprise to the researchers was that the varicosities disappeared several minutes after puffing, indicating that they are not a sign of irreversible axon degeneration.
Gu and colleagues could also induce axonal varicosities by repeatedly puffing cultured neurons with shorter bursts of liquid, mimicking the effects of repetitive, subconcussive impacts. Accordingly, the team also saw axonal varicosities in the brains of mice subjected to repeated light blows to the head.
The researchers found that puffing activated a mechanosensitive channel protein called TRPV4, which is enriched in the membrane of neuronal axons and allows calcium ions to enter the cell. Inhibiting this channel blocked the formation of axonal varicosities.
After entering axons through activated TRPV4 channels, calcium ions appear to disrupt the microtubule cytoskeleton by inhibiting a microtubule-stabilizing protein called STOP. This interrupts the transport of cellular materials along axonal microtubules, causing these materials to accumulate at several points along the axon where they may give rise to varicosities.
Older neurons, which are more resistant to the effects of puffing, express lower levels of TRPV4 and higher levels of STOP. “It will be interesting to determine whether these factors make a mature brain more resistant to mild traumatic brain injury than a young brain,” says Gu.
Puffing didn’t induce varicosities along the lengths of dendrites, the parts of neurons that receive chemical signals from neighboring nerve cells. Instead, the researchers found that dendritic, but not axonal, varicosities could be induced by prolonged treatment with glutamate, an excitatory neurotransmitter that is released from damaged axons.
“Taken together, our findings provide novel mechanistic insights into the initial stage of a new type of neuronal plasticity in health and disease,” says Gu, who points out that axonal varicosities have also been observed in healthy brains where neurons may respond to mechanical signals from their environment. “This process may therefore play a key role in neural development and central nervous system function in adults, as well as in chronic brain disorders and various acute brain injuries.”
Hackney Publications has announced that the latest Concussion Litigation Reporter has hit the streets, completing its first five years in this very important space
The following articles appear in the latest issue:
- Appeals Court Frees School District of Hospital Company’s Indemnity Claim in Concussion Case
- Judge Grants Summary Judgment to Arena Football One
- WIAA to Provide Concussion Insurance for Member School Student-Athletes
- North Carolina Return to Play Lawsuit Puts Spotlight on Such Protocols
- Discovery and Spoliation on Center Court in Concussion Case: Bouchard vs USTA
- Concussion Defense Lawyer David White Sounds Off on the Rising Tide of Concussions and Mounting Litigation
- Harvard Report Compares NFL’s Health Policies and Practices to Those of Other Professional Sports Leagues
- Equation Makes It harder to ‘Outsmart’ Concussion Tests, like ImPACT
- NCAA Moves to Eliminate Two-a-Day Football Practices
(Editor’s note: the following was written by Iseult Cody and initially published in www.nflconcussionlitigation.com)
A wet October morning. A field outside Roscrea, an unremarkable town in the midlands of Ireland, a rugby heartland, where men are men and pride in a jersey comes before all else. Thirty men on a field chasing an oval ball with maybe the same number again on the side-lines watching.
Supporters of a certain size and gender dare not get too close to the team manager for fear that if a substitute is needed they could be drafted in. There is no stand, no television cameras, no TV match official just the players, the officials and the supporters, maybe 60 sets of eyes follow the ball as it slips from muddy hand to hand weaving through the players. The jerseys are faded, the lines on the field are smudged but the passion is evident with every run, every tackle, and every kick.
Everything will be left on the field, they will give it everything they have and for no reward, there is no cup, they won’t be paid, they won’t get recognition save for from the small assembled crowd or a by-line in a local newspaper or tweet from a supporter. This is a religion in itself and this scene is repeated across the country every weekend throughout the season.
Suddenly a shoulder collides with a head, a man drops to the ground, he touches his hand to his head, and the team doctor who incidentally doubles up as the kit man runs on, glancing over his shoulder to see who is on the side-line potentially ready to enter the field of play if needed. He asks the right questions but is reassured by the player that he is fine. The doctor scurries back to relative warmth of the side-line the game continues on.
This is amateur rugby. This is the heartbeat of the game. This is the reality.
A different picture unfolds before our eyes. The scene is set, it is the 6 July 2013 at the ANZ stadium in Sydney. Eighty-three-thousand-seven-hundred-and-four sets of eyes will watch every movement, will feel every hit from their seats, will discuss every blow, will follow every movement as fifteen Lions take to the field with the intention of mauling, both literally and figuratively, the Australian Wallabies. Millions of eyes across the world will follow the ball on their TV screens, watching not only the live action but the replays.
Four minutes in and pulses are already racing, Wallabies legend George Smith (who incidentally returned from retirement for the game) has the ball in hand and collides with 250 pounds of Welshman in the form of Richard Hibbard. The initial hit almost has the effect of bringing time to a standstill, every viewer almost feels the reverberation as Smith’s head bounces of Hibbard’s shoulder before landing to the ground with a thud unable to prevent his own fall.
The medics race on, the spectators hold their collective breath, on the side-line Michael Hooper throws off his training top and races onto the field as the replacement.
The supporters are still discussing how sad an end to his career it is for Smith and hoping his injuries are minor when he emerges from the tunnel before running back onto the field.
One could be forgiven for questioning whether the team doctor had himself suffered a blow to the head in allowing Smith back on. This is professional rugby. This is the elite. The is with the eyes of the rugby supporting world watching.
In the wake of the game Smith himself acknowledged the severity of his injury, World Rugby, in its former guise the IRB, stood up and took notice. The rules changed, safeguarding player welfare became the headline issue, excuse the pun.
The “6 Rs” – recognise, remove, refer, rest, recover, return – should be the mantra when we witnessed a potential concussion, it should be instilled in our memories and in every participant, every coach, every official, every parent. Rugby would not fall into the pitfalls of NFL in seeking to distance themselves from concussion or shirk their responsibility.
In the wake, Rugby would protect its players from themselves. In a sport where physicality is inevitable, and indeed a requirement of the playing of the game, to protect players you have to take an almost parental approach and make the decisions for the players as to what is in their best interest. Rugby would change, rugby would adapt and rugby would protect their biggest asset, their players.
Fast forward three years and despite the rule changes, the negative publicity, the experiences of litigation in other jurisdictions and other codes and the awareness of the potential long term effects of successive repeated blow to the head, on 3rd December 2016, Northampton’s George North flies through the air as he collides with Leicester’s Adam Thompstone before landing directly on his head, apparently knocked clean out.
North, who has suffered a number of concussions throughout his career, departs the field of play only to return within minutes having undergone the HIA (Head Injury Assessment) protocols.
The sense of déjà vu was frightening to the scene witnessed in the ANZ stadium and indeed to the countless other instances in the intervening years of players receiving blows to the head and yet remaining on the field of play or leaving only to return.
The sceptic amongst the rugby fraternity may suggest nothing has changed but we (the rugby supporters and players) are now more educated, more aware, more sensitised so there is an immediate investigation into the conduct of the club in allowing Smith’s return to the field undertaken by Premiership Rugby and the RFU, and they issue guidelines but no sanctions are taken.
The complaints at the lack of action reverberate throughout the rugby community like North’s head against the turf, so World Rugby takes action and a strongly worded statement issues emphasising how seriously head injuries must be taken, that the protocols must be adhered to but yet again there is no sanction.
The situation posed a new question, if the procedures were followed and North was still deemed fit to return to the field of play then perhaps the question is are the protocols fit for purpose? What is to prevent a player dismissing the team doctor’s queries, he is the professional, the valuable commodity to the team, what if the team is losing and this is the “star” player; who is to say the doctor doesn’t look the other way or doesn’t see the signs that another doctor may?
Doctors differ and patients die but at the end of the day it is accepted that the HIA isn’t the only assessment of potential concussion, a player may satisfy a doctor conducting the HIA but still have suffered a concussion. The time may be approaching where a clear injury sustained to the head should have the effect of removing a player from the field for the remainder of the game with the HIA conducted to determine what further period of exclusion a player should have prior to their return to play.
Rugby related litigation to date has been largely focused on injuries sustained in scrums whereby players have suffered serious injuries as a result of collapsed scrums including players rendered tetraplegic however matters seem to be, pardon the pun, coming to a head now particularly with three sets of proceedings which look to shake rugby to its very core.
The first set of proceedings were instigated in Manchester by former Sale Shark Cillian Willis. Willis’ proceedings claim that his premature retirement from the game resulted from his taking two separate blows to the head during the course of a game. After the first blow the medics deemed Willis fit to continue but the second blow would see him crossing the side-line for the last time as a player.
The second case is being taken by Jamie Cudmore against his former club Clermont Auvergne. Cudmore’s case which cites his former employer’s negligence in exposing him to potential further injury in allowing him to play on, is particularly remarkable given that after this incident he went on to continue his career and indeed is still playing with French side Oyonnax. Cudmore may face an uphill battle in showing the injury or damage caused if his case were to go before the courts, but many commentators would expect this matter to be settled prior to that possibility. Cudmore himself is quite frank in his comments on contact sport and his comments on the matter illustrate a player’s perspective of the matter.
The third case which may prove to be the catalyst for the biggest change to head injury protocols or indeed for underage sports in general is the tragic death of Benjamin Robinson.
Benjamin holds a unique accolade, one that no one would want and one that has broken the hearts of his family, friends and teammate’s alike: he is the first person in the United Kingdom to die as a result of Second Impact Syndrome playing rugby, as determined by the coroner.
At 14 years of age Benjamin took not one, not two but three blows to the head during the course of a schoolboy’s rugby game. Benjamin collapsed and was treated on the field as his helpless parents looked on. Benjamin would later die in hospital with the coroner noting three separate brain injuries which in all likelihood represent the three blows sustained in that fateful game.
In the wake of his death his parents became aware that one of the opposition had recorded the match and suddenly they were faced with the harrowing prospect of reliving their son’s death on camera but also having the opportunity to dispel any notion of his death being a tragic freakish accident.
His death had to bring a positive legacy, it had to be the catalyst for change and could not be allowed to be in vain. Benjamin’s parents have now launched proceedings against various defendants including the school, the IRFU (governing national body for rugby in Ireland) and World Rugby. The case is one which they acknowledge won’t bring back their son but it may protect another family from suffering the loss they have had to endure.
For those of us who love the game of rugby, Benjamin’s smiling face pictured in his jersey is a poignant reminder of why rugby has to change, Rugby has to protect the future of the game, the participants who can’t be expected to protect themselves. Benjamin’s face should remind us of what is at stake.
The reality is players are getting bigger, hits are getting harder but the brain doesn’t and can’t protect itself any more now than it could yesterday. Two opponents collide, they both are stronger than their counterparts 10 years ago but their brain hasn’t changed, that strength doesn’t afford it any more protection or safeguard it from injury.
In our first tort class we learn the “eggshell skull” rule whereby the defendant will be responsible for the consequence of their actions no matter how remote or unforeseeable they may be; it is hardly that unforeseeable to picture the result of repeated blows to the head incurred during the course of rugby being chronic traumatic encephalopathy (“CTE”), as seen in the NFL.
The game has changed from so many perspectives, the physicality, the professionalism, the regulations but the biggest change needs to now be how World Rugby deals with head injuries or instances of suspected head injuries, not just to protect itself but to protect every participant and to ensure no family has to endure what the Robinsons have had to. Rugby for many is not just a sport, it is a way of life but no life should be lost in the pursuit of sport.
Iseult Cody is a practising lawyer in Dublin, Ireland with Eoghan P Clear Solicitors where she specialises in Property and Probate Law. As an avid sports enthusiast she has recently completed the first Sports Law Diploma course through the Law Society of Ireland and hopes to further expand her practice into Sports Law related matters.