In this episode Dr. Daniel Correa speaks with legendary U.S. soccer goalkeeper, Briana Scurry. Briana reflects on her journey as a professional athlete who experienced multiple concussions and how they impacted her physical and mental health. Briana also talks about the treatments and therapies that helped her overcome her brain injury. Next Dr. Correa speaks with Dr. Michael Jaffee, neurologist and professor of neurology at the University of Florida and co-author of the newest addition to the Brain & Life Books Series Navigating the Challenges of Concussion. Dr. Jaffee discusses the different types of concussions and traumatic brain injuries along with the typical progression of symptoms and various treatment protocols.

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Episode Transcript

Dr. Correa:
From the American Academy of Neurology, I'm Dr. Daniel Correa.

Dr. Nath:
And I'm Dr. Audrey Nath.

Dr. Correa:
This is the Brain & Life podcast.
Audrey, did you play soccer growing up?

Dr. Nath:
Only a little bit. I was never good at it. You, I think, played a lot more soccer than I did.

Dr. Correa:
I grew up playing soccer. It was the thing I did during the spring and summer, and then pretty much my winters were filled with wrestling.

Dr. Nath:
Didn't know that you did wrestling. I mean, I don't know all that much about soccer, but as a neurologist, it's one of those things that does come up that brain injuries are possible. I mean, I'm from Texas where it's football country, and that's usually how we see most of our concussions in clinic.

Dr. Correa:
So in this episode, I get to interview soccer legend and goalkeeper Briana Scurry. So anyone from the nineties who watched those nineties women's soccer team play through the Olympics and World Cup, they may recognize her as the number one, the wall that stopped so many goals that made it possible for those teams to move forward. I really was excited to interview her and she shares her experience with TBI, post-traumatic headache, chronic post-concussive syndrome, and all the mental health impacts that can come with recovery from injuries in sports and particularly after traumatic brain injury.

Dr. Nath:
We definitely need more athletes to come out years after the prime of their career and talk about these things, because otherwise you know you're watching that game and it's just like magic without knowing that there's these repercussions that can last years or decades or a lifetime.

Dr. Correa:
And then upcoming next week, stay tuned. We're bringing back by popular demand, Dr. Craig Stark. You may remember him from our episode with Mary Lou Henner, and he'll tell us some more about what we really know about memory in our brains. And do you think photographic memory actually exists? He'll explain.

Dr. Nath:
I want to hear this. And then on March 23rd, I got to talk to the accomplished power lifter Javeno McLean about how he opened a gym exclusively for people with disabilities and the elderly and it's completely free. Check it out.

Dr. Correa:
Welcome back to the Braden Life Podcast. Whether you're new to soccer after the last World Cup, maybe a child of an eighties and nineties, or a footballista, many of us remember the amazing rise of the nineties US Women's Soccer Team to the top of the world soccer stage and into all of our living rooms. Growing up playing soccer as a defensive player myself, I noticed especially today's guest as the world's best goalie at that time. She's broken many barriers in many different ways. Briana Scurry is a Hall of fame, US goalkeeper of the Women's Soccer National Team with 173 game appearances from '94 to 2008.
She brought home to us two Olympic gold medals, a World Cup. She played a pivotal role in soccer history as one of the first African-American female players and has helped diversify the sport, and joined efforts for pay equity for soccer for all women in professional sports. In 2022, she released a best-selling memoir, My Greatest Save, and was featured as a subject in a CBS feature documentary The Only. In each she shares not only her personal story throughout a storied career, about her experience and the impact of traumatic brain injury recovery, mental health challenges, and much more. Thank you so much, Briana for joining me here today.

Briana Scurry:
Thanks for having me.

Dr. Correa:
Well, Briana, can you take us back to one of the iconic soccer moments that you treasure from your time with the team?

Briana Scurry:
Well, I think probably the most iconic for everyone is save in the penalty kick shootout in '99 against China in front of 90,000 fans at the Rose Bowl in 107 degree heat. The third kicker stepped up, her number was 13. And I remember going into the goal, and usually I don't look at the players coming to kick, but something in me said to look at her. And I looked at her and I knew this was the one that I was going to save. And so I went into the goal knowing that no matter where she kicked that ball, I was going to get it. That's probably the most memorable and iconic moment that I've had.
But for me personally, my performance in the 2004 Olympics against Brazil in the final was probably one of the most iconic moments for me, that entire game. My father had passed away two months before, and I was feeling every exaggeration of emotion you could possibly imagine, joy with being back at the Olympics again and able to potentially win another gold medal like I had done before, and then absolute sorrow knowing that one of my greatest supporters and my heart and my mind wasn't there with me, but he was there in spirit. And so that game against Brazil was probably the most iconic and personal for me.

Dr. Correa:
Well, his spirit helped you stay pretty much a wall for that whole game and then for the team. So it's an amazing video to go back and watch for anyone who's now gotten more interested in soccer. Now you came to soccer in a bit of a unique way that you talk about in your book. What was your experience growing up as a soccer player?

Briana Scurry:
So like many of my teammates, I was the only girl on the boys team my first year because I grew up in a really small rural town in Dayton, Minnesota, which didn't have any stoplights, maybe just over 2000 people. And so I came up what I call through the back door with regards to national teams. Most of my teammates played youth either U15, 17, U19, 20s, but I didn't do any of that. Most of them, if not all of them, played regional pool teams. I didn't do that either. And so I was very fortunate to have a lot of athletic ability, a lot of talent, and was seen by my club team coach, Pete Swenson, as someone who had the potential to play on the national team.
And then he relayed that feeling he had to Jim Rudy who was the head coach at University of Massachusetts in Amherst, and I decided to go to UMass after Jim offered me a full scholarship on Pete's encouragement. And from there I took it and went to UMass and played incredibly well my four years there. And then was brought onto the national team a week or so after my last collegiate soccer game. And then from the national team in November of '93 at number five on the totem pole of goalkeepers, I went from five to one in about four months. So March '94, my first game I was a starting keeper.

Dr. Correa:
Wow. Sounds like you had an amazing time in career both playing at UMass and then playing along our international teams. If we can't, we want to just get to some of the discussion that you cover in your book talking about concussion and traumatic brain injury. If we can zoom forward, what happened in 2010 during what ended up being your last professional soccer game?

Briana Scurry:
I played with the Washington Freedom in the W PS, which was the second version of the Women's League. We are currently now in our third version of NWSL. So I was playing with the Washington Freedom in 2010. We were in Philly playing against The Independence. And ironically, earlier that afternoon, I had a weird feeling about the game. And it's so interesting to look back on that. Similar to the feeling that I had about the penalty kick shooter, I've had these inclinations or these intuitions, if you will, a few times in my life a handful of times, and this was one of them. And I had a weird feeling about the game and I didn't know what it meant. I thought maybe it was going to mean we were going to lose or something, but as it turned out, it meant that my life was going to be forever changed.
And so I played that game against Philly. There was a low ball driven from the left hand side. I was scooped down to get it. And fortunately for me, their attacking player I didn't see coming from my right, trying to nip in front, get her toe in front of the ball to play it around me, ended up crashing into the side of my head with her knee. My first question that I had was did I make the save? Because spoken as a true athlete, did I make the save? I realized yes, in fact, the ball was in my arm. So the save was made, but I stood up and my life was forever changed. On the backs of my teammates jerseys, their names were blurry. I remember listing and tilting to my left, just having really intense pain in the right side of my head where she hit me, but also in the left behind my ear.
And at the time, I didn't understand what that meant. Took me three years to realize what that was. And I just had all these symptoms and I actually continued to play that half, which was not a good idea. The culture of athletes is to fight through it. And back then in 2010, we didn't know what we know now. So in everybody's defense, they just figured I would shake it off and I kept waiting for that to happen. And then the halftime came and I kind of was standing there and my trainer came walking out to me and she looked at me and I was walking towards her kind of going to the left. And she's like, "Bri, are you okay?" And I looked at her and I said, "No, I'm not okay." And that was the last soccer game I played.

Dr. Correa:
It took you years to work through recovery and symptoms. You talked already that initially, you already had some issues with blurred vision, some issues with balance, a few different focal pains. Over time, what were the different combination of post-traumatic brain injury or post-concussive symptoms that you ended up trying to find a way to manage and live through?

Briana Scurry:
Yeah, so up until that point, I had had two documented concussions. And by the word documented, I mean, we knew I was concussed, two were both from the front, by a teammate falling on my head, my head going into the ground and the ball coming off the post. And I saw both of them coming. And so that was a day or so of rest. So I knew I had several concussions on the books, but I didn't realize how many I had because at the time, we didn't realize what a concussion really was. And so I had a basket of symptoms, the usual suspects being pain on that side of my head. I had blurry, blurry vision, dizziness. I had sensitivities to light movement, sound, forgetfulness, inability to focus and concentrate.
And then those are the physical symptoms. Inability to retrieve information. My trainer asked me to remember the three words. I couldn't remember the three words. And at the time, we had done baseline testing, which is pretty much standard now, but at the time it wasn't. I bombed five baseline tests in a row and then got the sixth one only because there was a repeat of one that I had already done. But I knew I wasn't okay. It had been a couple days I wasn't getting better. And it was interesting because the symptoms would ebb and flow, and so I would maybe be feeling a little bit better one day and then really horrible the next day and thinking I'm coming out of it. But I woke up every morning hoping I was going to feel better and I just didn't.
And these symptoms continued and they got worse and worse. And the surprising part for me was the emotional piece, which a lot of people really didn't understand back then, and I feel like I'm one of the few people that talk about it openly now, is having anxiety, which I never had before, inability to focus, which obviously I never had a problem with before either. Being able to focus with 90,000 fans holding their breath at 107 degrees. I mean, I had a very keen sense of focus that I was actually very, very proud of and I couldn't do it. I couldn't remember stuff and I just felt like depressed and I wasn't sleeping and all these things.
And so I started self-medicating with alcohol and I did have some Vicodin that I was given from my doctor for the pain. And it was just a bad combination and it wasn't getting better. And I kept being told that I was okay after a certain amount of time, but I knew I wasn't. And so I was very firm about that. Normally an athlete wants to get back as quickly as you can. Maybe somebody working a job they don't like, they might stall a little bit. But as an athlete, I wanted to get back at it as soon as I could and my career had ended and I wasn't getting better. And I knew there was something really wrong and I needed to get help for it.

Dr. Correa:
I really appreciate you putting into words so much of what the symptoms are that people deal with. I saw a lot of it during my time working in the military at Walter Reed and through time with also people coming in and out of the hospital. And over time now we've started to learn more about concussion and mild traumatic brain injury and its more severe types, especially in sports. And several studies have shown high school, college and professional players, particularly also women and soccer are at risk for these head injuries. There were a few other times that you had maybe a concussion and a head injury but with a different progression and different set of symptoms. What was your experience in high school or college when you may have had one of these more minor injuries and then your ability to return to play? How is that different?

Briana Scurry:
Soccer is a very interesting game. It's very intriguing. It's not considered a contact sport, but there's a lot of collisions. I mean, you've seen the World Cup. You know what I'm talking about. And sometimes those collisions are because you're battling out at a high level and sometimes the collisions are because people are maybe a bit clumsy or they get to into a slide tackle a little bit late or a challenge a little bit late. I had been upended several times coming out for a cross, not necessarily banging my head on the ground, but that movement, that whiplash movement. Or somebody crashing into me with their body and my head hitting the ground. Normally for all those times that that had happened before, I knew my bell was rung. That feeling, you're like, ooh, I'm a little woozy. And back in the day, coach would be like, "Okay, go sit it out for a minute."
And then as an athlete you're like, okay, well I remember where I am, so I guess I'm okay now. But as it turns out, I wasn't. All these times I was still feeling headaches and whatnot, but I just didn't think anything of it. I didn't think it was from that. I didn't think it was from the hit. I thought it was from maybe dehydration because you train and you sweat like crazy and maybe you didn't replace the liquid, or I'm a little hungry and maybe I didn't eat enough. And all these reasons that weren't the concussion for why I felt the way I felt sometimes. But I never had the emotional change in any time before other than that last time. I never had a feeling that I wasn't me or I was disconnected or that I was just someone else. I didn't feel like that until that last time.

Dr. Correa:
So it could take you maybe a little bit of time to recover and get to play. And some of the things we start to pay attention now when we talk about return to play or return to activities. And in terms of noticing symptoms with activity, maybe there wasn't as much attention to that in the past. But what was newer for you was just the added level of the mental health and the cognitive changes that occurred. And then especially it sounds like the duration of how things lasted. You couldn't get back to any of the activities.

Briana Scurry:
Absolutely. I mean, like I said earlier, I was waiting for me to return. And day after day, every morning I'd wake up and take an assessment. And this is something I did all the time anyway, and I still do this about where my life is and whatnot and how I feel. But I was waking up with this headache, mild, mild headache, always on this side, always on the left. And I'm like, what is that? Where's that coming from? What happened there? And I didn't realize that it was from that hit. It wasn't until I met a doctor almost three years later, Dr. Crutchfield, where he explained to me why that felt that way.
And also the emotional piece and the symptoms should have gone away, but I was still feeling so disconnected, and just not into any of the things that I normally would like to do. I had a real actual personality change. In myself I noticed it. My partner at the time, she noticed it. And I just was not me. And it was almost like it was an out of body experience. I was watching me in a different way. It was very strange, hard to explain at the time. And I didn't realize that I had all these issues with recovering information, which ended up tripping me up in a few different things over the years back then. And I realize now that that was all part of the same thing.

Dr. Correa:
And in our medical expert discussion following this for our listeners, we'll be touching more on some of the specific symptoms of concussion or mild traumatic brain injury, the typical progression of symptoms. But I'd like to come back to your focus and discussion on some of those mental health changes, and struggling through all these different symptoms and looking for a direction of return to you, as you said, and the mental health challenges. It really seemed to add up over the years to the point where you needed to identify for yourself a lifeline.

Briana Scurry:
Yeah, I really struggled. Looking back on it, it was a really deliberate, slow slide into almost like an abyss, and to the point where everything in my life was just not me anymore. And I just found myself in this teeny tiny studio apartment in Little Falls, New Jersey, and it was almost like the big huge person I had been, the personality, the big athlete, the big presence that I had, just was getting smaller and smaller and smaller as I was sliding into this hole. And it was like I was disappearing, the person that I was, little by little. And I just didn't know how to get out of it. I tried and tried to get the proper healthcare that I needed and I had a battle with the insurance company to do that. And it was just so discouraging. And being told that I looked fine all the time and I know I didn't feel fine, the invisible injury, I just knew that I needed to do something because I was sliding.
And I got really depressed and I became suicidal at one point in a good chunk of 2013. And the thing that got me reversed course into being more proactive and more hopeful was I had an image of my mom when I was standing on the edge of a waterfall near my house that was raging because it had rained really hard recently, and this waterfall was a good drop, several dozen feet drop, and I don't know how to swim. So I knew if I jumped in, I wouldn't survive it. And what kept me from doing that was the image of my mom who was also battling Alzheimer's, like late stage at the time, police officers having to inform her that her baby was gone. And I couldn't do it to her. And that's what got me off that ledge. And then shortly after that, literally a few weeks later, I was really thrown a lifeline in the form of a new person in my life who was told by my former partner, Naomi, that I needed help and if she could help me.
And she said yes, she would help. And that person is my wife, Chryssa. And so once she came onto the scene with her PR understanding, she owns a PR firm, she was like, "Well, we need to get this insurance company to do the right thing by you, and I know how to do that." And so she went to my lawyers and they talked and they basically threatened him and said, "You better do the right thing by Bri or everybody's going to know about it, and I don't think you want that kind of heat." And a couple days later, I had my permission to get my procedure done that was experimental. I had the permission to see the doctor I wanted to see until I was feeling like I was better and doing the suggestions that they made and I was on my way. And within a year or so after that, I was on a much better footing.
And so that was the beginning of the turnaround. But it took a lot. It took a lot of time and a whole year of therapy and that procedure being successful for me, which was occipital nerve release bilateral, that worked for me with this part of my issue, which was these headaches that emanated from behind my left ear that were basically making me crazy. I mean, that constant pain was essentially making me insane basically because it just kept hurting and hurting, and every day would be there. Constant pain wears you down. It really does. And it did for me. But finally I got some relief from that.

Dr. Correa:
And when Chryssa helped you connect with Dr. Crutchfield and getting this evaluation, there were some treatments that they tried out to see how you responded to this irritation to the nerve in the back of your head as you described, the occipital nerve. We call it occipital neuralgia, basically the inflammation or irritation to that nerve. What do you remember about that treatment and when they tried those injections? How did that go for you?

Briana Scurry:
So it was so interesting, and it's frustrating too because the way Dr. Crutchfield was able to see if I needed this treatment, if it thought it would work for me, was he touched it. He examined me with his hands. And when I told him about what I was feeling and my issues, he touched it and I literally almost jumped off the table and kicked him because it hurt so much for him to touch it. He was like, "Okay, okay, I see that." And then he said, "Okay, go to the other side of my office by the door and close your eyes and walk towards me." And I was listing to the left as I was walking. He's like, "Okay, you have some balance issues." And it literally took 15 minutes of a treatment investigation to see what would work. And so that's when he decided that I had occipital nerve neuralgia.
And he's like, "Okay, I think I have a treatment that will help." He's like, "Let me try these steroid shots first, and if you find you have a lot of improvement, then I think you're probably a good candidate." And sure enough, I couldn't believe how much better I felt with those headaches. Now I was still bumping into stuff at that point, but at least the headaches were better. And then of course the shots wear off, but that's okay because he understood that I was a good candidate for the procedure and we did it. And of course the insurance company paid for it. And then another year of therapy for all the other cognitive balance issues that I had, retrieval of information learning and all of that we worked on for a year after that.

Dr. Correa:
Yeah, I mean that's important to highlight. This helped you remove the issue and trigger for a lot of the pain.

Briana Scurry:
Yes.

Dr. Correa:
That prevented you from being able to really get the benefit and participate in some other therapies and even the rest. But it wasn't a treatment for the other things.

Briana Scurry:
Right.

Dr. Correa:
What were some of the other therapies that helped you progress along the way?

Briana Scurry:
So one of the things that my occupational therapist wanted to know about if I was riding bicycle or elliptical or something like that, would symptoms start to flare up? And so sure enough they would. And so we had to work on calming those things down. Also, I had to relearn a few things. I had to use my hand-eye coordination, my balance. We had to essentially recalibrate by doing these exercises by standing on one leg and then closing my eyes and trying to balance and then feeling how that felt. And then also I was in this dark room and there was this big board up and I had to touch the light that shown up with the letter and say what it was and touch it. So that was a speed, a receptive kind of cognitive link I had to make. And then they would time how long it would take me to touch it and say it and all of these different things and doing it over and over again until I got to be faster at it.
And then also there was an intake on did you go to the grocery store since the last time you were here? How did you feel? Did it seem weird? Have you been out to eat or anything? And hearing people talk around you, are you able to focus on the person that you're having dinner with or is it just too much stimulation and you start to feel like you're overwhelmed? And all these feelings that I didn't understand why I was feeling that way, we started to really pinpoint a lot of different things. And so there was this literally a hundred question intake form that I would do every time I came there. And are you feeling this a lot or sometimes or barely? And over time, things started to resolve. And I think that the occipital procedure really basically took the initial cloud off of everything so that I could actually think about other stuff because that pain was so constant, it just completely distracted me from everything. And so once we got that handled, we were really able to work on the other stuff.

Dr. Correa:
Looking back, would you do anything differently with the way you played on the field or your journey after your injury?

Briana Scurry:
You know, a lot of people ask me that, and I honestly can say I would not change a thing. And I think the reason is because A, I'm far enough away from the really difficult, hard times in my life where I can have a perspective on them that's a little bit more objective because I'm not in the forest trying to get out. Also, people like, "Well Bri, you went through three years in the wilderness with your head injury." And I am like, "Yeah, I did. But without it, I don't have my wife who is the most amazing person I've ever met who loves me unconditionally, and I just cannot believe my luck."
And so there wouldn't be a day where I would change a thing. I wanted to be an Olympian since I was eight years old. And my entire life I've lived this dream and chased it down, and was lucky enough to play on the pitch in three Olympic games and win in two of them and win silver and the other one. And so I honestly would not change it for the world. I feel like I was meant to do this. I was meant to have this kind of impact. I was meant to use my God-given skillsets and my athleticism that my mom gave me in my mind, that my dad gave me, and do what I have done with them. And so I wouldn't change it for the world. I mean, I have truly built a legacy with myself and my teammates and I'm very proud of that.

Dr. Correa:
Oh wow. Well, Bri, it's such a pleasure to get a chance to talk to one of my own sports heroes, to get a chance to discuss and hear from you your experience and the awareness that you're bringing not only to mental health challenges and sports, but traumatic brain injury and everything that you've done to step forward as a role model and to push forward the efforts to diversify sport and bring equity and pay equity for women in sports and in professionals areas. And truly, I can't say enough, and I'm so glad you could join us.

Briana Scurry:
Thank you. It's so great to be here with you and thank you for including me. And now you are a part of my journey now, so thank you for including me and it's been fantastic talking to you.

Dr. Correa:
Is this episode leaving you wanting more? Get the latest tips on Healthy Living and management for more than 250 neurologic conditions by visiting brainandlife.org where you can learn more about neurology every day powered by trusted neurologists.
Welcome back. Now after that great discussion that we had with Briana Scurry, I'm here now with a colleague that I've been waiting to have a chance to interview, Dr. Michael Jaffe. He's a professor in the Department of Neurology at the University of Florida, and he also has specialty certifications in sleep, behavioral neurology, brain injury medicine. He did his neurology and sleep medicine training in the US Air Force in San Antonio where he also helped countless military service members in their management and recovery from brain injuries. He completed a 21 year career with the Air Force where he served during wartime and as a leader, as the National Director of the Defense and Veteran's Brain Injury Center. He served as a consultant for the Institute of Medicine, the North Atlantic Treaty Organization, National Institutes of Health, and the NFL.
He is recently the author of the newest release in the AAN's Brain and Life book series. This great books are an amazing resource that combine the expertise of neurologic specialists, valuable insights from other experts in the field, patients and caregivers, to help them and their families understand and manage conditions. They cover things from brain tumor, Parkinson's, Alzheimer's, stroke, and many other conditions. Dr. Jaffe's newest release tackles concussion and traumatic brain injury. He covers how concussion is different from other forms of brain injury and what to expect after a concussion and what do symptoms look like and how do they persist. We thank him so much for taking the time here to be with us and we're looking forward to this discussion.

Dr. Jaffee:
Daniel, it is my absolute pleasure to be here.

Dr. Correa:
So Dr. Jaffe, now after we asked you to do the hard work of writing a whole book on these complicated topics, now we'd like to somehow get you to summarize some of these ideas in just 20, 30 minutes of a interview.

Dr. Jaffee:
I'll do my best. One thing I can say about the book in general is one of the things we tried to do was put a lot of the conversations that we've had with patients over the years about some of the more challenging aspects of this in an understandable way in the book. And so hopefully the book captures a lot of the conversations you would have with a knowledgeable provider who's trying to explain what's happening to you.

Dr. Correa:
So just had a great discussion with Briana about her soccer career, bring up how more studies and efforts to monitor head injuries have found soccer to be particularly one of the sports where people can have a higher risk of head injuries. And she talks about her own journey after her head injury. One of the types of doctors that people might encounter in this situation like we described for you have a specialty in brain injury medicine. But you're also a neurologist, so really what's the difference between those certifications?

Dr. Jaffee:
That's a great question. And so brain injury medicine is one of those medical specialties which is considered multidisciplinary, which is basically a fancier way of saying that there's more than one specialist who can achieve that certification or training. And so board certification and brain injury medicine is actually a joint collaboration between the American Board of Psychiatry and Neurology and the American Board of Physical Medicine and Rehabilitation. And currently physicians who would be eligible to get that additional certification with the appropriate training would be neurologists, psychiatrists, PMNR physicians, and certain sports medicine physicians who were part of the original group that developed the guidelines for the board certification.

Dr. Correa:
Now we had a previous episode where we touched some about concussion and TBI, but I want to come back to the types and what are the distinctions between what is concussion and then there are different types of traumatic brain injuries? So can you explain that for our listeners?

Dr. Jaffee:
Sure. So the classifications of traumatic brain injury are basically mild, moderate, and severe. And I just want to say that this is not the best classification. It is really these distinctions have nothing to do with how severe are the symptoms affecting the individual. They have a lot to do with what happened at the time of the injury itself. Was there an alteration or loss of consciousness? If so, for how long? How long did it take for someone to regain normal memories after being injured? And so these things all sort of add up and there's different sort of rubrics for how one would grade mild, moderate, or severe. So the term concussion typically gets used almost as a synonym for mild traumatic brain injury and that these are injuries that have limited time of a loss of consciousness. They have a limited time of having post-traumatic amnesia.
That being said, we've had plenty of patients who have had a mild traumatic brain injury based on that system for classification who symptoms might be persisting. And these patients don't like that term because it's not a great one, and I totally agree with this. So even though it's called mild traumatic brain injury for someone who may have had a concussion whose symptoms are persisting, it's not mild to them if it's affecting their life and things along those lines. And so sometimes I wish we had a better classification system, but it's important to realize that when we do this classification system, it's primarily meant to enhance knowledge and research and how do we divide up these injuries when we're looking at outcomes and treatments? But I do wish we had better terminology because it can be misleading for people who don't understand that it has everything to do with what happened right at the time of the injury and not as much to do with how they're affected at the moment.

Dr. Correa:
That's such a challenging and an important aspect for us to understand and for everyone to understand. It's really just descriptors on certain characteristics on a scale that was created a while back. And there's a whole variety and even some disagreement in that. And Briana is a perfect example of that in many ways, some people would categorize in that scale her injury as mild traumatic brain injury. But as we heard in her story, it was such a severe impact not only in her life, her mental health, her career, and I'm sure she and all the people around her wouldn't have described it as mild.
I think one other interesting thing is some of the things that go into that categorization or that scale of the injury, it was developed even before and didn't necessarily include some of the MRI techniques and other imaging and other tools that we have now for diagnosis. So how does that end up informing more of what you know when someone you're reviewing how the kind of impact of a brain injury for someone when those things weren't necessarily included in the mild, moderate and severe designation?

Dr. Jaffee:
I think that's an excellent point and it adds a whole bunch of heterogeneity into what we're calling mild traumatic brain injury. And that if you look at some of the classification systems now to have a concussion, a lot of people would say you have to have a normal imaging. So meaning you have a CAT scan of the head and there's no bleeding or anything that can be seen at the time of that. So a lot of people when they have a head injury, they go to the ER and one of the first things the ER does is they put them through a CAT scan to make sure there's no bleeding. That being said, if we took these definitions of mild traumatic brain injury like we just talked about, you can have someone who meets those clinical criteria but has an abnormal head scan. And so depending on which system of classification you use, some people would still call that mild.
And in fact, if you look at some of the research that's been done on longitudinal outcomes, those patients are included along with those who didn't have abnormal CAT scans. And to me there's a big difference between those populations for us to better understand how best to approach them and for what the long-term outcomes may be. And so I think what you're hitting on is what we also hit on in part of the book is that concussions and head injury have been around a long time. We've been dealing with that problem a long time. But our understanding is really accelerating and is really much different now over the past several years, over the past decade than it once was. And one of the reasons why we are having more of this understanding is because of the advances in diagnostic technology to include advances in neuroimaging and regular neuroimaging.
And so the more advances that we have, it's going to be important for us to figure out how best to help people. And it also makes us an incredibly exciting field of neurology to be in because advances are coming fairly rapidly, looking at biomarkers and how we might figure out better how someone has, whether or not someone has had an injury, whether someone is responding to treatment, what the long-term prognosis might be. And so the more research that's happening, the more we are better understanding this issue. And one of the things that makes this challenge different than a lot of the other things we deal with in neurology is that what we are talking about when we are talking about a concussion is a transient disruption in the function of the brain that may not necessarily be due to actual structural damage. And so we are basically interrupting the networks of communications between neurons and that's taking them a while to kind of heal and recover those more efficient communications with each other, as opposed to stroke where you're actually seeing damage directly to brain tissue itself as an example.
And so when we do an image and there's not bleeding or something there, but the patient clearly had an injury and is clearly symptomatic and you can even see this on your evaluation, it has more to do with this transient disruption. And again, there are some anatomical aspects to that, meaning there are some stretching of the what are called the axons. And so certainly those are the communications between neurons. So even though you're not having that loss and death of neurons themselves, you are definitely having an impairment in their functioning the way they're supposed to function, which is can be responsible for a lot of the symptoms that we see. And that's what makes it challenging.
And that's why especially in the military, some people have referred to this as an invisible injury because you can't necessarily see it when you're looking at the person and you may not always see it if you're looking at a regular CAT scan. And so just understanding the phenomenon of what's happening has been increasingly important to us to better understand and figure out how best to treat people and get them back on track and get them to recover.

Dr. Correa:
In the Navigating Concussion book, you cover particularly a whole section on post-concussive syndrome, and one of the things you go into is what we know about some preexisting conditions, other injuries and management issues that may end up being a cause or contribute to the longer duration of symptoms. Can you go into that a little bit more?

Dr. Jaffee:
We sort of think about it almost in a symptom by symptom or target symptom approach. So at a kind of starting point, you can consider that if one has a challenge to start with before being injured of a headache syndrome, which is requiring treatment or a clinical depression which is requiring treatment, that might make the individual more vulnerable to worsening those symptoms following the injury. So even if they are on a great medication regimen that has those things under control, they might temporarily have a flare or worsening of those conditions and that's important to be aware of. One of the things that we know can certainly negatively impact recovery is disruptions in sleep, disruptions in mood. That can certainly affect one's thinking and things along those lines. And then there are certain conditions that if the one has a learning disorder or already has some cognitive impairment, there's going to be some challenges.
And so there's a debate in the field whether the learning impairment such as ADHD, does it really cause a decrease in recovery or are we having a more difficult time assessing it with our neuropsychological tests because there's already going to be some abnormal findings on the testing? And so that's one of the challenging issues of the field that we are continuing to work through. One of the things that we have found in our older individuals who might have a very early dementia or a mild cognitive impairment is that when they have such an injury, one of the things that it's not clear that the injury itself worsens their cognitive impairment or gives them a more severe dementia, but what it does do is it takes away their ability to compensate for that mild cognitive impairment. When they can't compensate, it looks like it's a lot worse. So it's being able to understand that aspect of our evaluation as well.
And so the research is also leading us to learn more that there may be some genetic factors that people have that may be contributing to prolonged recovery. And it actually turns out that APOE4, one of the genes that has been associated with increased risk for Alzheimer's disease, that for people who are carrying that, that has been associated with a longer recovery following the concussion.

Dr. Correa:
So after your time working both in the military and in different civilian and academic medical centers and working on this book, what is some of the information that we know to understand the differences between the types of injury that someone might encounter with TBI or concussion, whether in the military, sports or occupational injuries?

Dr. Jaffee:
We do have a section in the book where we go into these different considerations about older individuals, military types of things. And so when we talk about military, we're oftentimes talking about a different mechanism of injury. If we're talking about combat, there might be a blast component to that and there's kind of a different physics that goes along with that. And there may be more than one mechanism of injury that our service members and veterans are dealing with to having to recover. And so it really comes down to understanding kind of the mechanisms and some of the challenges that go into people. And so for athletes, we have a very well defined system for return to play and where they have to be cleared for it. It's actually every state in the country now has laws that sort of apply to the public secondary schools where if there's any student athlete that has a concussion, they have to go through a whole process of being cleared by medical professionals following a graded return to play protocol.
So that's one of the kind of most defined systems that we have that's actually mapped out and actually has a lot of local law and jurisdictions kind of helping with that guidance. When we talk about occupational issues and returning to work, it really becomes an individualized aspect because many different people have different kinds of work. And so it almost becomes kind of a risk benefit for that individual depending on the nature of what they're doing for work. And at the end of the day, everything that we do for managing traumatic brain injury or for managing concussion has to do with safety. So if we talk about that sports protocol, it's about not letting an athlete go back into full competition when their brain might still be vulnerable. Because if you have another injury when your brain is vulnerable, it can actually have a more significant effect than the initial force itself would predict.
And the same thing with work. We don't want them going back into work where if they get too stressful because they aren't able to do everything they did before, that kind of stress and pressure and concentration can slow down the recovery and so forth. So we're trying to use that same idea of that graduated return. And in some cases with occupational issues, we try and kind of limit the activities they can do while they're recovering. And so if they are doing both physical and desk work, it might be that they do the limitations on both of those.
And so the other thing I did want to bring up was for our student athletes and the student comes before athlete. And so one of the things that we also work with with our student patients on is getting them fully back into return to learn in the classroom. They may need, while they're recovering, some temporary academic accommodations. But as we improve and they get better and they recover, we want to be able to get them back to where they were prior to the injury. And so there's an old clinical adage that we emphasize to all of our trainees, which is return to learn before return to play. In other words, an athlete shouldn't be back on the field where they might sustain another injury, while they still need academic accommodations from the last injury that they had. And there's not just the physical component to it, there's the kind of cognitive and memory and academic component as well.
So it really depends on everyone's different stage of life. Older individuals can take a little bit longer recover. We worry most about these individuals who might be on blood thinners if they have another injury because they're at risk for having a bleed in their head and we want to kind of protect them from anything like that that might happen. And if they, as older people have other medical comorbidities, they may be on other medications, that may affect the treatments that we can do as well. And so we want to be very cognizant and mindful of that as we are getting people back on the road to recovery.
And so when we talk about these different context of injuries, you mentioned the military. So there are now systems in place in the military where those service members get screened and are looking for a variety of comorbidities that might be affecting their recovery. And so that brings up another important thought that I did want to make sure that we had a chance to talk about and that when we talk about these symptoms from concussions or mild traumatic brain injury, there can really be a broad variety of different symptoms. And there's an old saying that no two people's concussions is exactly alike, which means that the symptoms that one person may have is not going to necessarily be the same as the symptoms that another person might have.
And so we think about the symptoms in sort of clusters. And so there are common what we call physical symptoms. And those might be things like headaches, dizziness, fatigue. There can be emotional symptoms, feeling irritable, anxious, depressed. There can be cognitive symptoms things like having trouble with attention, trouble with memory. And there can even be a variety of sleep disruptions. So some people may have most of their symptoms in one of those clusters. Other people may have most of their symptoms in another cluster. Typically what we see is multiple symptoms happening at once in an individual, but they'd all don't recover at the same rate. So whereas in some cases someone's cognitive issues might improve, but their headaches are persisting as one example.
So having to track all the symptoms that someone has, knowing that everything doesn't always get improved at exactly the same rate becomes an important aspect of how we approach the patient. Knowing that there can be a variety of these symptoms, it becomes important for the provider who you're working with to make sure that they're asking you about all the possible symptoms that you might be having. Because if they only ask you about the physical symptoms, then you're not left with a plan to deal with the cognitive symptoms, for example. So it's important to kind of have an approach where we're looking at all the possible things that can happen and building that and partnering with your provider to develop a treatment plan that can incorporate everything that's there as well so that we can get people to continue to improve and get them back to doing what they were doing before the injury.

Dr. Correa:
That's such a valuable consideration. Remembering that our lives are not all at one speed and one activity all the time, and we do so many different things. And having a consideration for the different activities and symptoms and that graduated return to activities might be different by the different types of activities, might be different in its effect to your sleep or getting back to exercise or going to work and having more cognitively intense activities. Now you mentioned this graduated return to activity and to me that stands out particularly different from some of the things we used to hear about a kid or an elderly person who has a head injury. And there'd be someone in the family or someone saying, "Don't let them fall asleep at night. Someone should be in the room keeping them up." And it's someone else saying, "No, you should just let them rest and sleep," all of it. Like those old strategies and misconceptions, how do you address some of those and what are some of the other ones that we should be aware of?

Dr. Jaffee:
So I think the big idea that we're talking about is going back to that aspect of don't let them sleep at night. That really a concern of what would be an epidural hematoma. And that is kind of a serious but a typical complication of bleeding that can develop after you're doing well for a while. So you're injured, you're doing well for a while, and all of a sudden the blood slowly builds up until it sort of takes its toll and causes some pressure on the brain. And so in our modern era of assessments and evaluations, once we know that that's not a possibility, and if you have a normal CAT scan, then you know that that's not going to be a possibility, that sort of advice goes out the window.
I think the more important aspect of what you mentioned was this issue of don't let them do anything. We want to protect them. So you would take an individual, keep them in a dark room, not let them do any activities. There's a term for that. It's called cocooning where you kind of just want to wrap a protective cocoon around the individual. And that used to be the standard for many, many years where people were being very protective and it was done out of good intentions. But it turns out that is not the best approach to get people back as quickly as we can. Because if you kind of almost think about it as deconditioning, you're further deconditioning an individual from a cognitive perspective and from the rest of what they need to do. And so cocooning is no longer thought to be the way to go.
We are really trying to get people to start doing things in a very graduated way to kind of help facilitate the recovery. And there's actually a number of studies that show that cocooning people for an extended period of time can prolong recovery and make it longer to eventually get back on track. And so I think that goes along with one of the older fashioned approaches to how we were dealing with, which was done out of nothing but the best intentions. But isn't it fantastic that we live in an era where we can kind of have modern research, which is kind of helping to reshape the way that we are approaching patients and getting them to get better more quickly?

Dr. Correa:
When you tackled the book, if you were thinking of, okay, what are some key things that you want people and their families to take away from concussion and concussion management, what would be sort of your top choices?

Dr. Jaffee:
Well, number one is awareness of what it is or isn't. And so for example, a lot of people have the idea that, "Well, I might have gotten bonked on the head, but I didn't have a concussion because I didn't lose consciousness. I didn't black out." That's not exactly correct. And so it turns out that if you look at some of the studies, you can have a concussion up to two thirds of concussions are done with what's called an alteration of awareness, but not necessarily a loss of consciousness. And that means you can have so many other symptoms that go along with that. And so if you kind of misunderstanding that, you're not going to be able to approach it or treat it in an appropriate way. And that management or approach might be the safety aspect from the beginning to kind of targeting the appropriate symptoms.
But the other aspect that stood out for me when you asked me that question, Daniel, was you used the word management. And I just want to emphasize that. Because one of the things that has been I think challenging over the years is I've seen many patients who are told, well, yes, I had a concussion and my doctors just told me to just wait it out. And so there really wasn't any treatment interventions that were being done for that individual. They were just kind of waiting it out. And then weeks became months, and in some cases months became years. And so one of the things that I think that we do describe in this book is the variety of treatment approaches that one can do to help people recover more quickly. And those treatments have a lot to do with the target symptoms that we're talking about beyond just waiting it out.
The treatments can involve medications. They can involve certain types of procedures, they can involve certain types of rehabilitation modalities and they can involve other technologies. But the treatments that we talk about in the book all have good evidence-based and we have all seen patients improve from them. And so one of the things that the message I have for on our listeners as well as our fellow providers is to take an active role in management because you want to shorten the course of this. Yes, they might get better over time, but they might not. But if we treat them, we can certainly shorten the course and kind of make their lives better more quickly. And so one of the things I would like to do is just to kind of raise more attention to the variety of treatments and approaches that can be done that can make people feel more safe, that can allow people to be able to get these types of symptoms that are better targeted.

Dr. Correa:
And that echoes for me something that really came up in our discussion with Briana about her head injury. And she dealt with a lot of issues impacting her both her sleep, her mental health. But particularly one of the things that disrupted her ability to try to manage those other things was the headache and a headache that came from a lot of nerve and neck pain in the back of the head, and particularly a lot of sensitivity over one side of her head and always that one side. And really for it seemed like for years, she was just sort of waiting to recover from that instead of trying out treatment. She eventually ended up finding out it's what they call an occipital neuralgia. So how often do you see that with concussion and mild traumatic brain injury and other types of TBI? And can you talk some with us about how you approach initially treating that?

Dr. Jaffee:
So it's actually pretty common, especially if you have a mechanism that has to do with almost that whiplash or flexion extension of the neck. And the way I have thought about this over the years is that one of the things that happens in that response to trauma is that the muscles in the back of our neck, they kind of clamp down and get tight. And there is an area in the back of the head on each side where we have the occipital notch, where the occipital nerve kind of comes out and supplies kind of the upper part of the head on each side and the scalp. And so when the muscles clamp around that, it's almost like pinching on the nerve, which can cause that kind of pain or discomfort to happen. And so the first thing is to figure out is to realize that that might be a contributor or a component to the headache pain.
And so I've expanded my exam and evaluation. So when I'm seeing a patient who's had this kind of complaint, I'm going to check their range of motion in their neck in all directions. I am palpating in the back of the head for areas that might be tender, be they tight muscles, be they what are tender trigger points. And if I can actually reproduce that pain when I press in on that occipital notch, I can actually have many patients where that pain starts going forward and it's similar to what they have. It may not be the same severity. But if I can reproduce that discomfort from that maneuver in my exam room, pretty confident that that's kind of what I'm dealing with. And so muscle relaxers have not done the job with this individual, then we start talking about whether starting off with kind of a tier of procedures might provide some relief.
And so doing an occipital nerve block, it's kind of a low tech type of situation that a lot of people can do that can oftentimes bring relief to a lot of people at least for several months at a time and can help confirm what we're dealing with there with the diagnosis. And so that it doesn't require any X-ray or fluoroscopy. It just can be done pretty simply. And so knowing that that can be a part of the process and looking specifically for that kind of what I call a secondary occipital neuralgia, and I call it secondary because of the muscles clamping around it, and knowing that that can be such a common feature of these kinds of injuries.

Dr. Correa:
And for her, she had occipital nerve blocks and she had an excellent response initially to them, but it seemed that it had been around for so long that the nerve blocks never really had a sustained benefit for her. She ended up seeing a team of physicians who ended up recommending and completing for her an occipital nerve release. And I know there were release procedures. There's ablations. Does everyone eventually end up needing to go to one of these procedures or what's the context for doing one of those procedures?

Dr. Jaffee:
So I mean, the reason that we have a tiered approach is because a lot of people will respond to that lower level types of treatments first. So not everyone needs that kind of release for ablation.

Dr. Correa:
That's good. That's reassuring.

Dr. Jaffee:
So sometimes it's just through manual physical therapy or using physical therapy with modalities to help get those muscles a little more relaxed. Sometimes just the occipital nerve injection then with the occipital nerve block itself can provide people enough sustained relief to kind of get them through their entire recovery. But it's good to know that at each stage that if one of these things doesn't work or completely bring relief to the individual, there is a next step in that tier, a next step of the procedures that can. But certainly the majority of people who have that problem don't need to go to that level. But for those that do, we're fortunate that it does help a lot of people.

Dr. Correa:
Thank you very much and so much for taking the time with us and to discuss both concussion and traumatic brain injury, and the efforts and what you put together for the Navigating Concussion book.

Dr. Jaffee:
It's been a pleasure and I had some fantastic co-authors for the book. And so one of the things that was important for us was to kind of work as a multi-disciplinary group to kind of show all the different aspects and avenues of treatments and understanding for people. And so all of us are really hopeful that it is a good summary of our distilled wisdom and what we talk with patients with when we see them in clinic. And so we hope it can provide a lot of help for a variety of people. And it has been an absolute pleasure.

Dr. Correa:
And to our listeners, you can find the links to the Brain and Life book series and this and many of the other books in the show notes and on the website for the podcast. Thank you very much.
Thank you again for joining us on The Brain and Life Podcast. Follow and subscribe to this podcast so that you don't miss our weekly episodes. You can also sign up to receive the Brain and Life magazine for free brainandlife.org.

Dr. Nath:
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