REAL HEAD SHOT

Dr. Kim Gorgens is a full-time faculty member at the University of Denver. Kim has a Ph.D. in clinical psychology, completed a postdoctoral fellowship in clinical neuropsychology and is Board Certified in Rehabilitation Psychology. At the University of Denver, Kim teaches in the Clinical Psychology doctoral program, the Forensic and International Disaster Psychology graduate programs and at University College. Additionally, Kim maintains a faculty appointment with the University of Colorado School of Nursing and is registered as an expert with the American Psychological Association.

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Should You Let Your Kid Play Football?

The blog post below is the extended interview that I did with Amir Khan from US News & World Report. You may read his final article here, as well…Enjoy! Should You Let Your Kid Play Football? How to balance the benefits of organized sports against the risk of the gridiron  by Amir Khan

Q:  What is the importance of organized sports and exercise for children?

KG: The neuropsychological benefits are staggering. We are just beginning to understand the role of aerobic exercise in brain plasticity—the brain’s ability to respond dynamically to the environment. We understand now that there are a few areas in the brain where humans benefit from neurogenesis or ‘growing new neurons’—the most ‘plastic’ or responsive of these areas is the hippocampus.

The hippocampus is associated with working memory and for consolidating memory from short term to long-term storage. The hippocampus is vulnerable to all manner of problems with demonstrable reductions in volume resulting from drug and alcohol use, childhood abuse, stress, depression, sleep and seizure disorders and more.  Those hippocampal neurons are very sensitive to disruption—thankfully, they are also very responsive to intervention.

The principal way to ‘build’ the brain is to promote hippocampal neurogenesis which we know includes learning new things (like a language or musical instrument) and, even more strikingly, aerobic activity.  With increased hippocampal volume and function, we see improved memory function in people from childhood all the way to adulthood.

The findings are incredibly robust for kids—as their, brain and body fitness appears to be the same thing. There is also an area of study which suggests that kids learn best when they engage their entire bodies (and not just their brains)—this research suggests that physical activity is ESSENTIAL for learning and retention.

Organized sports are a learning lab for life—they steep kids in everything from frustration management to diplomacy and collaboration. Data suggests that involvement in team sports is associated with higher high school graduation rates for boys and girls (likely this is also partly attributable to the benefits of exercise outlined above). Actually, when we are reviewing applicants for our graduate programs at the University of Denver, I cherry pick the students with backgrounds in team sports because I’ve seen that they excel under the pressure of graduate school.

Q:  Is football a good option for kids to stay in/get in shape? For kids interested in football, participation allows them to reap the benefits associated with physical exercise and team sports. Reduced contact models of football would be even better.

KG:  What are the major risks of kids playing football? How do they compare to the risks of other sports, like basketball, baseball or soccer?

The entire conversation about brain injury and concussions and sub-concussive blows focuses on football as a kind of ‘conversational short-hand.’ It’s not the only sport that imparts a risk of injury to players, but it has become front and center for several reasons. Football accounts for more total injuries than other organized sports, (according to athletic trainer research) however concussions account for only about 13 percent of those injuries (vs. 22 percent in ice hockey). Furthermore, it is important to realize that the risk of a catastrophic injury (e.g. severe brain and spinal cord injury or death) related to football or any other sport is miniscule (according to data collected by the National Center for Catastrophic Sport Injury Research at UNC Chapel Hill and a youth database managed by my colleague Dawn Comstock at the University of Colorado).  Using that metric—participating in any sport, football included, is all upside.

The caution about football and all other contact sports is that there may be more to the story than the few very tragic, high-profile cases where a young athlete dies.  As a field, neuropsychology is beginning to better understand the functional consequences of even a single concussion—we see changes in brain function (e.g. metabolism and cognition) for weeks and months after an injured athlete identifies as ‘symptom free.’  We now know that younger brains are more vulnerable to those kinds of mild injuries (related to brain development and neck strength among other things) and there is some reason to be thoughtful about the long-term implications of early concussive injuries for career athletes (younger age of first concussions has been associated with reductions in brain volume and poorer outcomes among professional athletes).

There is also an emerging area of study around the sub-concussive impacts to the head that characterize all contact sports (including heading the ball in soccer and body contact in football, hockey and rugby). A study from 2009 and 2010 reported that high school football players sustained an average of 774 head impacts in a single season (the high was 3700) and college players an average of 1444 (interestingly the g force of impact was higher among high school players). The same model holds true with soccer, where player brains (without a history of concussion) show changes in white matter relative to swimmers for example. When you think about the accumulation of thousands and thousands of head impacts over the course of years of sandlot and club games, scrimmages and intramural sports in high school and college, the wisdom of subjecting the young brains to that barrage of blows seems dubious. If we could change the style of play to reduce the frequency of impact, then the accumulation of those blows seems needless.

Q:  How do parents balance the risks and benefits? Ultimately, should they allow their child to play, or should they have them choose a different sport?

KG: Our understanding of concussions is that nearly every kid with a ‘good brain’ should recover fully within a few weeks from a (first) concussion—a good brain here reflects both structural integrity and cognitive reserve. Sport-related concussions (when they are identified) are almost always managed well by families, athletic, school and medical professionals—all in the service of recovery.  That said, as a neuropsychologist and parent, I am made more cautious by appreciating what we don’t know and the ‘not knowing’ makes a truly informed decision about risk more difficult.

For example, we don’t know why a few kids don’t recover after a single injury or why even fewer kids have catastrophic outcomes after second injuries (e.g. second impact syndrome). We know even less about the risks that exposure to thousands and thousands of sub-concussive head impacts imparts.  On that front, we don’t know yet understand why some people with that injury history develop neurodegenerative disease or pituitary dysfunction and others do just fine over time.  We do know that there is a relationship between exposure to concussive injuries and youth depression, being bullied (and being a bully) and substance abuse.  We also know that, despite their capacity for recovery, younger brains are more vulnerable to injury and recovery times are longer.

There is promise that we may be able to identify genetic, physiological or psychological vulnerabilities that can be used when making decisions about which sport to play.  In the meantime, parents should be reassured about the risk of a single concussive injury (which characterizes every sport and human activity out there) and should be more cautious about impact sports which, by virtue of the style of play, subject players to repeated blows to the head (concussion or otherwise).

The fence-sitting parents can advocate for models of flag-football for younger players or reduced contact practices for high school players (a la the NFL) for example. They might also engage their kids in strength conditioning to maximize neck and shoulder musculature.  Worst case would be for a parent to assume that the researchers, coaches or PTA know everything about the risk and worse still, for parents to feel powerless to make decisions or prevent those injuries.

My kid has been unfazed by my stealth efforts to steer him towards reduced contact sports (which I’d hoped would include something sedate like lawn bowling but is actually basketball this season); he has never come to us with a request to play football.  Knowing what I do, I would be all for flag football and completely opposed to tackle football.  This for my junior high school student who, like many boys his age, has a history of one concussion already (snowboarding). There is also no early indication that he’d be a Heisman trophy candidate, so I can pretty handily dismiss the option of football, for now.

Q:  Is there anything else I should know?

KG: On a related note—the stakes are higher and the conversation very different for athletes who already have a concussion history. I spend a lot of time with young people and their parents after a first injury: the decision to return to a specific sport is very difficult (recognizing the likelihood of future concussions is greater and the recovery from subsequent injuries arduous). I have colleagues whose model is to promote tennis and rifle team scholarships for those athletes…

Kim Gorgens is a nationally recognized expert on Psychophysiology and Clinical Neuropsychology.  She is a Clinical Associate Professor in the Graduate School of Professional Psychology at the University of Denver. Gorgens lectures extensively on Traumatic Brain Injury and her expertise on the field of psychology has appeared on NPR, CNN with Anderson Cooper, USA Today, Salon and The Washington Post.

A brain and a baby-maker walk into a bar….

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by Kim A. Gorgens, Ph.D., ABPP

70–90 percent of the millions of traumatic brain injuries sustained each year are mild (mTBI) and aversive cognitive and emotional symptoms are common immediately after that kind of injury (see Carroll et al., 2004).  Thankfully, we know that nearly everyone who sustains a concussion or mild traumatic brain injury returns to their baseline function within three months–most people with those injuries report a full recovery within two weeks.  I say nearly everyone because we also know that somewhere between 1 and 8 percent of injured persons do not (see Ruff, 2011 for an excellent overview of the discrepant data.  And, for reasons we don’t fully understand, women are over-represented in both the number of concussions and in the ‘miserable minority’ who don’t recover fully.

Our understanding of that predominantly female, ‘miserable minority’ is fairly sparse despite decades of attention.  To date, there are dozens of studies examining the enduring REPORT of symptoms (which includes a body of research with support for faking bad and “good old days bias”), the enduring OBSERVATION of symptoms (with data to suggest that our diagnostic tools yield too many false positives) and the enduring EXPERIENCE of symptoms (with an interesting body of work on nocebo effects [n.b. those account for belief-defying phenomena like voodoo, spells and hexes], a patient’s vulnerability to suggestions that they may experience on-going symptoms, and vocal support for a model that attributes the experience of enduring symptoms to pre-injury psychopathology or the ‘already broken’ hypothesis).

The latter phenomena is troubling—as a field, psychology has a dubious history of assigning pejorative labels to the problems we are obliged to treat as if the label confers some additional clarity or absolves us of our responsibility to provide humane interventions.  This is especially true for the complaints of female patients.

A noteworthy, albeit historical, example is the first explanation of ‘madness’ in females as the spontaneous wanderings of the womb “hither and thither in the flanks” (that being a quote from physician and Hippocrates-contemporary, Aretaeus of Cappadocia).  Additionally, Charcot, a neurologist and early pioneer of psychological sensibilities, coined the term ‘hysteria’ from the word for uterus to describe the emotional presentation of his female patients with traumatic accidents in their past (which he reported to include “a fall from a scaffold or a railway crash”). He wrote that those women suffered, “not from the physical effects of the accident, but from the idea they had formed of it.”

But what is there to suggest that there may be more to these ‘miserable minority members’ than pre-injury melodrama?  There has been an exciting proliferation of neuroscience research in this area.  Research now suggests a role for persistent dysfunction in the blood-brain barrier and the existence of pre-injury physiological vulnerabilities to poor outcomes (whether conferred by genetics a la APOE ε4 + genotypes, illness exposure, or previous injury).  There is also some indication that migraineurs (a lovely French word for people who suffer from migraine headaches) are over-represented in the miserable minority members, as are people with idiosyncratic metabolic and inflammatory responses to injury.

David Hovda recently went so far as to say “Both animal models and human studies strongly suggest that there is nothing ‘mild’ about mild TBI at the cellular level.”  But, even with an explosion of research attention, the truth is we know much less about these injuries among young and adult women.  In fact, many of the larger studies of recovery from mTBI among healthy young people include predominantly male populations (see Cancelliere et al., 2014 for their systematic review of 77,914 articles on the topic).  Someday we may find that making assumptions about the applicability of these models (nearly all of which are based on male populations) to injured females was, at best, premature and, at worst, reminiscent of Aretaeus.

Our patients bear the consequences of arrogant, stigmatizing or misogynistic policy (whether athletic, healthcare, or social).  We can assume that the persisting symptoms experienced by these women and men reflect the complex and dynamic interplay of physiological, psychological, social and cultural variables.  Given the expanse of this area of study, there is no reason to believe that any one variable accounts solely for clinical outcomes.  And if we are to benefit from our rising consciousness about the inanity of itinerant reproductive organs as an explanation of emotionality we need to be especially careful when assigning reductionistic motives to a group made up largely of women.  When we unwittingly communicate the message that “this is all in your head” (pun intended) we may unintentionally foreclose scientific inquiry, drive persistently symptomatic patients away from the resources meant to proffer support (to them and their families), reinforce ugly gender stereotypes and risk coming up on the wrong side of history (again).

Cancelliere, C., Cassidy, J.D., Li, A., Donovan, J., Côté, P., & Hincapié, J.P. (2014).  Systematic

Search and Review Procedures: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis.  Archives of Physical Medicine and Rehabilitation, 95 (3), p. S101–S131,

Carroll, L., Cassidy, J., Peloso, P.M., Borg, J., von Holst, H. & Holm, L. (2004). Prognosis for

mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of Rehabilitation Medicine, suppl 43, p. 84–105.

Ruff, R. (2011).  Mild traumatic brain injury and neural recovery: Rethinking the debate. Neurorehabilitation, 28, p. 167-180.

Protecting the Brain Against Concussion

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Why you should listen

In a lively talk, neuropsychologist Kim Gorgens makes the case for better protecting our brains against the risk of concussion — with a compelling pitch for putting helmets on kids. (Filmed at TEDxDU.)

http://www.ted.com/talks/kim_gorgens_protecting_the_brain_against_concussion

As a neuropsychologist working in the field of brain injuries, Kim Gorgens has seen firsthand the damage sports-related impacts can do. And as chair of the State of Colorado Traumatic Brain Injury Trust Fund Board and a member of the Brain Injury Legislative Collaborative, she’s working to shape Colorado law around youth sports injuries.

Gorgens, an assistant clinical professor in the University of Denver Graduate School of Professional Psychology, also is the president-elect of the Colorado Neuropsychological Society and has an appointment to the American Psychological Association’s Council on Disability in Psychology.