CHRONIC TRAUMATIC ENCEPHALOPATHY (CTE) is the only PREVENTABLE cause of dementia” … according to The Center for the Study of Traumatic Encephalopathy (CSTE) at Boston University School of Medicine.
THIS IS NOT A SIMPLE CONCUSSION INJURY. CTE used to be associated only with boxers and was called, ‘punch drunk syndrome’ or ‘dementia pugillistica’ and thought to originate from repetitive blows to the head during a boxer’s career. However, brain research is showing that any activity that results in severe and repeated blows to the head can result in symptoms including altered levels of consciousness, headaches, memory loss, confusion, impaired judgement, poor concentration, paranoia, problems with impulse control, irritability, personality changes, gait abnormalities, weakness, sensory losses, incontinence, depression, increased symptoms with exertion and eventually progressive dementia similar to Alzheimer’s disease.
Activities where these types of activities can occur include contact sports such as football, soccer, boxing as well as military personnel who are involved in blast injuries. In addition, almost two-thirds of concussions in cheerleaders occurred from two-level pyramid falls.
Most physicians will use CONCUSSION SCALES WITH RETURN TO PLAY CRITERIA including the Cantu system and the Kelly systems which evaluates up to four levels of severity and time of loss of consciousness, confusion and post injury amnesia for up to three concussion injuries.
Repetitive head injuries can be complicated by SECOND-IMPACT SYNDROME (SIS) where a second head injury occurs before the symptoms from the first head injury have been resolved. Symptoms can appear initially mild, looking like a daze. However, a second impact can cause cerebral edema and herniation, which can cause death within minutes.
Neurological examinations need to include verbal quality and appropriateness, memory, orientation, cognitive testing, visual assessment including pupillary size, reaction, tracking, nystagmus, visual fields and diplopia. Motor assessments need to include coordination, strength and balance. Other neurological testing includes Romberg testing, Tone, reflexes and sensory testing including touch, pinch and pain. Radiographical imaging studies need to include plain skull radiography, head computed tomography, and MRI of the head. Neurological evaluation also needs to include historical information of previous head injuries, persistence of any symptoms, alcohol or illicit drug use. In addition, a complete neurological evaluation would consider any involvement or effect of possible multiple diagnostic differentials including brain masses, cerebral contusions, dehydration, hyperthermia, diffuse axonal injury, epidural hematoma, intoxication, medication side effects, meningeal irritation/infection, seizure disorder, subarachnoid hemorrhage or subdural or intracerebral hematoma.
Treatment of an initial brain injury can take up to 18 months, and can include symptom management of dizziness pain, and cognitive effects, with medication management, surgical intervention, as well as physical therapy, occupational therapy, speech therapy and recreational therapy.
Helmets and protective gear are not the exclusive answer. The problem is the repetitive travel and shear of the brain inside the skull. The key to diagnosis of CTE is examination of brain tissue [before or after death] to determine the integrity of “tau proteins”. An accumulation of tau proteins creates “neurofibrillary tangles and threads” throughout the brain. This is different than other progressive neurodegenerative brain diseases. This trauma can be localized in one section of the brain, or in a diffuse distribution in the brain tissue.
Prevention of debilitating or fatal outcomes includes safety gear, but also accurate evaluation and recognition of concussion, prompt treatment and patient and team or work compliance with recommendations for treatment, leave of absence from participation or military duty.
Prognosis of concussion syndromes and CTE depends on the extent of the injury and application of appropriate and rapid emergent treatment. Depending on the injury, most often, repetitive injury can have a worse outcome than a single injury in terms of a long life with a poor cognitive and neurological capabilities and quality of life.
B. WHAT COULD A LEGAL NURSE CONSULTANT DO WITH THIS CASE? My TOP 3 TO DO LIST:
1. FIND A CENTER OF EXPERTISE: Center for the Study of Traumatic Encephalopathy at
Boston University; www.bu.edu/cste
2. FIND THE LATEST EVIDENCE BASED RESEARCH: Academic Articles
a. Repetative Injury Guidelines
b. Click on this link for the latest list from the CSTE at Boston University:
3. REQUEST ALL MEDICAL RECORDS: from the time of the initial injury to the time of the current disability. Including:
a. Initial Injury: Hospital, Field Reports, EMS Reports, Emergency Room, Tests,
Consultations, Hospitalization, Discharge Plan
b. Any repeated hospital or physician examinations, consultations or
1. Patients/Families will often seek care at a variety of hospitals, urgent
care centers or physicians based on EMS emergency transport
guidelines, or independent proactive searches.
c. CHRONOLOGY: that includes initial injury, symptoms, evaluation and care AND, any subsequent injuries, persistent symptoms, evaluations and treatment plans.
Reference: The Center for the study of Traumatic Encephalopathy at Boston University School of Medicine
[Original post 01/19/2013]