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KPBS Midday Edition

Effects Of Repeat Head Trauma In Sports And Combat

Michael Lobatz, Brain Injury
We get some insight on Chronic Traumatic Encephalopathy
GUEST:Dr Michael Lobatz, Neurologist, Director of the Rehabilitation Center for Scripps Health

CAVANAUGH: This is KPBS Midday Edition. I'm Maureen Cavanaugh. Football great, Junior Seau, will be remembered as a private family memorial this evening in Oceanside, and tomorrow San Diegans get a chance to celebrate Seau's life at a memorial at chargers stadium. It's still not known why Seau took his life last week. Researchers hope they may get closer to an answer if they are allowed to examine his brain. What they'll be looking for are signs of a degenerative brain disease called chronic traumatic encephalopathy or CTE. In recent years, medical science has seen it more frequently in athletes and veterans. I'd like to introduce my guest, neurologist doctor Michael Lobatz, director of the rehabilitation center for Scripps health in Encinitas. Welcome to the show. LOBATZ: Thank you very much. I'm glad to be here. CAVANAUGH: It's my understanding that doctors used to think this continue was only found in older, professional boxers. And that its slang name was punch-drunk. When did it start showing up in other athletes? LOBATZ: It's probably been the last 5-ten years that we're getting to be more familiar with the idea that people may have long-term effects. CAVANAUGH: When did the military start recognizing CTEas a problem? LOBATZ: The idea of a concussion occurring during combat has been known for quite a long time. But the effects of those concussions that were occurring in soldiers really became evident in the last few years, with the current conconflicts. And probably the reason for that is that the survivability of soldiers who are being injured is much greater today because of the marvelous triaging and technology that the military now has in the field. So we're seeing more survival, people coming back with their problems of concentration, memory, headaches, and changes in personality that occur commonly with these kinds of injuries, and that made it much more evident. And those people started showing up to the military institutions, and the healthcare providers there, and got refer forward those kinds of evaluations and treatments. CAVANAUGH: Now, we've done a number of shows on -- about traumatic brain injuries, suffered by people who have gone to Iraq and Afghanistan. In fact, it's been called the signature injury of the wars in Iraq and Afghanistan. What is the difference between traumatic brain injury and CTE? LOBATZ: Well, a single injury, like a single concussion or blast injury that might occur is a single injury to the brain, whereas chronic traumatic encephalopathy implies that there are multiple areas of the brain that are involved. And in some of the autopsy studies that have been done on people who have had multiple brain injuries, including boxers as well as now NFL football players, we're finding that there are multiple areas of involvement on a microscopic bases, and changes in the protein chemistry within the brain itself that actually may be causing the symptoms that we're seeing in them. CAVANAUGH: And what are the symptoms? Do they too deviate in some way from traumatic brain injury? LOBATZ: With the traumatic brain injury, what you typically see is an individual who develops symptoms fairly quickly following the injury. And those symptoms tend to get better in a large majority of patients. In a small minority, they may persist, but in CTE, after a number of these injuries occur, and with aging on top of that, you see a progressive degeneration of the brain, and increasing problems of memory, cognition, personality change, the appearance potentially of depression, and things of that nature, that occur at a later point in time. CAVANAUGH: Is there any way to do a test to see if someone has developed or is developing CTE? LOBATZ: Not really. There are imaging techniques that we currently have available to us, such as CAT scanning and MRI scanning. That's available in most hospitals today, would not be able to deconnect something like this. We are going to have newer imaging techniques that are much more sensitive and can pick up these changes early on. But for the most part, right now, the only way to really make the diagnosis -- definitively would be at the time of death and autopsy of the brain. CAVANAUGH: It's suspend since CTE has been found in other athletes who have taken their lives that it may have contributed to the suicide of Junior Seau, although no one knows that for sure. And we're taking your calls if you have a question about this degenerative brain disease. You can give us a call at 18888955727. Frequent condiscussive injuries can occur in a variety of sports. It seems to me football is probably the prime example. LOBATZ: That's correct. It's the No. 1 cause of concussion for kids in college. The No. 2 cause of concussion is cheerleaders, interestingly. And when you think about it, the acrobatics done by students today doing that, there is an increased incidence of concussion related to that as well. The incidence of brain injury in the United States has been rising. The CDC now estimates that there's about 1.5 to two million brain injuries a year in the United States. The military portion of this, be and the athletic portion of this is actually the small minority. Most injuries are occurring in auto accidents and in falls. The other interesting fact is that it used to be brain injuries were more likely to occur in auto accidents. Now it's been falls. And it has to do with our aging population. CAVANAUGH: Ah. LOBATZ: The baby boomers aging and becoming unstable in their gait. And an increasing number of falls. CAVANAUGH: It seems to me that concussion in and of itself hasn't been taken terribly seriously by the medical profession for a long time. Especially when you bring up something along the lines of sports. Student sport, high school, college sports. It's frequent that someone will run off the field for a while, and if they can kind of shake it off, you know what I mean, and not perhaps being kept out of the game long enough to make sure that they're really okay and examined as potentially having suffered a concussion. LOBATZ: Well, that's true. It's only in the last year and a half that even the American academy of neurology, the group that really writes guidelines and helps neurologists to understand what the right thing to do is has established the recommendation that all student athletes who are involved in a concussive injury during a game are not returned to play until they are examined by a physician who actually knows something about concussion and knows how to return an athlete to play in the proper sequence. It used to be before that that the recommendation was that if you were so-called dinged on the field, but you returned back to normal within 15 minute, you could return to play. And now we know that that's really not a very good thing. And that recommendation change only occurred in the last year and a half. CAVANAUGH: We have a person who couldn't stay on the line who wanted to know if one event can cause the same symptoms. LOBATZ: Well, the symptoms of a concussion would be something like memory loss, headache, blurred vision, dizziness, light-headedness, balance difficulties, there might be changes in the ability for an individual to sustain attention or do multitasking, more things than one at a time, and when that occurs and it's persistent, in a small percentage of people, that would be a brain injury. And the same symptoms can occur in traumatic encephalopathy, but that is more progressive in nature and changes as a person ages. CAVANAUGH: Does it actually change the brain? LOBATZ: No, it's the other way around. The CTE itself is induced, and the theory is, and there's research about this, and more needs to be known about it, needless to say. But the theory is that it induces changes in the protein chemistry in the brain, and some of the things that we're seeing in these brains of these individuals as reported by the researchers at Boston university are similar to the changes that we're seeing in patients with Alzheimer's disease and Parkinson's disease. And other neurodegenerative disorders, which is why there is a theory that CTE represents a degenerative condition that progresses with time, and that its onset is due to injuries. And that is right now theoretical, it needs more testing and research. CAVANAUGH: What is the connection between CTE, depression, and suicide? LOBATZ: Well, let me go backwards from that. If you're depressed, you have an increased risk of suicidal idiation and having suicide occur. That comes with being depressed. And the development of depression can be due to a variety of different things. We know that 5% of the population in general have depression. About 5 out of 100. But we also know that up to 40% of people with brain injury can develop depression. So if you have that brain injury, you have depression, you are therefore at increased risk for the development of suicidal idiation. So there is a continuum there. But there are so many factors involved, in how or why a person would get to that point of suicidal idiation, that you really understand that that's an extraordinarily complex issue, and you really need to be careful about the assertions you make about that. CAVANAUGH: I completely understand that. Let's keep it to just CTE and depression. There are many medications now that are used to help people who are struggling with depression. But if CTE actually is beginning to change the way the brain is functioning, do those medications work to help relieve that kind of depression? LOBATZ: The hope is yes. But the actual study of those medications in CTE and patients who have depression, that's never been done. So though psychiatrists would probably use those kinds of medications in an attempt to lessen the depression, in other conditions of brain injury, we do know that there is some evidence that those medicines can help. CAVANAUGH: Now, I was reading something about CTE, and the military. And you can see how repeated head injuries in a sports career might lead to this kind of brain damage. But there's been some speculation that CTE is being found in veterans of Iraq and Afghanistan because of shock waves from explosives. Are they the same as concussions? LOBATZ: They are in a certain sense that it's a direct injury to the brain. But a blast wave injury may be very different than a linear injury from a football player hitting their head on the ground. The blasts are extremely powerful explosions with blast waves that compress air and compress brain structures and pass through the brain as a sort of a wave coming through. And it's thought that that mechanism of injury may be different than the other kinds that I mentioned earlier. And the biochemical changes that occur within the brain as a result of that could also be different. And there's an enormous amount of research now going on sponsored by the Department of Defense to really try to understand those differences, how to diagnose that, and more importantly, perhaps how to treat it. CAVANAUGH: Is the military beginning to screen for brain injuries in the field? LOBATZ: Yes, they are. The military has really adopted something that was really first adopted by the national hockey league, which is to test test soldiers, get a baseline of where they are from a cognitive and memory perspective, using a simple computerized test, put that into a database and store it away. And when they go into the field and have a concussive injury, they can retest them at that point, and then compare the results and see has there actually been a change. Before that, you really didn't know whether there was a change or not. And the soldiers, like student athletes, typically want to go back to their units, they want to be back in action like players want to go back into the field. And this now gives us a somewhat objective way to really understand whether or not there has been a change in their cognitive function or not. And this effort is nowing brought to the field in Afghanistan, there is a place in Afghanistan called camp leatherneck. I've had the pleasure of meeting the people that run that facility and put it together originally. And they are collecting an enormous amount of information now, and I think in the next year or so, we're going to be learning a lot more about the initial evaluation and treatment of that kind of blast injury concussive injury in the military. CAVANAUGH: Considering what you said that CTE is degenerative and it manifests itself often later in life. Do you think both the military and the nation in general needs to prepare for potential CTE injuries? LOBATZ: I do. I think that given that this brain injury is the signature injury of the war, and that they estimate that there are thousands if not tens of thousands of soldiers that have been exposed to these blast jers and have had concussive injuries, that we do have a potential major public health problem heading our way, toward the veterans' administration, and for those that care for these people as they age. CAVANAUGH: I want to thank you very much. It's some really very interesting information. LOBATZ: Thank you very much.

CTE Information

Center for the Study of Traumatic Encephalopathy

What is CTE?

A study in January found ex-football players are 59 percent less likely to commit suicide than non-athletes of the same age.

This statistic may call into question the theory that former Chargers player Junior Seau committed suicide last week as a result of head injuries he developed during his career.


But Michael Lobatz, director of the Rehabilitation Center for Scripps Health, said there is a link between depression and suicide and a link between brain injury and depression.

"If you have a brain injury, have depression, you are therefore at increased risk for the development of suicidal ideations, so there is a continuum there," he said. "But there are so many factors involved in why a person would get to that point that you really understand that that's an extraordinarily complex issue and you really need to be careful about the assertions that you make about that."

Lobatz said there are multiple types of brain injuries, including Traumatic Brain Injury, or TBI, and chronic traumatic encephalopathy, or CTE. He said TBI comes from one traumatic injury to the brain, while CTE is caused by multiple injuries to the brain and manifests as a degenerative process later in life.

He said CTE is like Alzheimer's or Parkinson's disease, where patients worsen over time.

"That's very different than a single brain injury where we typically expects patients to have their symptoms initially and then remain the same or get better over time," he said.


TBI is often seen in military veterans, while CTE more often impacts athletes like boxers and football players, he said. However, researchers are now exploring whether blast injuries might be causing CTE in veterans as well.

Lobatz said returning military who suffered concussions are now showing signs of memory and concentration loss, personality changes and headaches and dizziness.

Because returning veterans are still young, Lobatz said it is too soon to tell if they will develop CTE later in life, but added, "it's that group that we're very concerned about."

People with repeated brain injuries, including concussions, are especially at risk for developing CTE, Lobatz said. If Seau suffered from brain injury, it would likely be CTE.

Lobatz said among student athletes, playing football is the number one cause of concussions. The number two cause, he said, is cheerleading.

"And when you think about cheerleading, the acrobatics that are done by students today doing that, both male and female, there is an increased incidence of concussion related to that as well," he said.

Researchers hope to study Seau's brain to determine whether he suffered from CTE.