This is the first installment of a three-part series on concussions. Part 1 will look at the experience of concussion and new treatments; Part 2 will look at the ways area schools minimize risk for students who have suffered concussions; and in Part 3 we will hear about two athletes' experiences under their schools' new concussion management policies.

Josh Luttrell was playing soccer in the 2012 homecoming game at Camden Hills Regional High School when a leap to head the ball set his life’s path on a seven-month detour.

That September afternoon, Josh, who was an Oceanside High School West freshman, was about to experience a serious concussion that would change him from a social, active honors student and athlete to a bedridden patient, unable to walk, read or even handle more than 20 minutes of tutoring a day.

Josh did not end up heading the ball. He collided with another player and fell to the ground, landing on his head. When he got up and tried to walk, he fell again. He was able to walk off the field, but then began shaking — he was going into shock.

In the ambulance, emergency medical technicians were asking him questions but he couldn’t answer. His words came out mumbled, "like I had rocks in my mouth," he said. He felt a tingling and then a numbness move from his fingertips up his arms. When he got to the hospital, he lost his ability to walk.

At the intensive care unit, he couldn’t handle any stimulation — not even light or conversations. The sounds of his MRI scans were too painful and he had to push an emergency button to cancel them.

“I lived in darkness the first few days,” he said. During that time while he still could hardly move, he said, "all the worst-case scenarios were going through my mind."

Josh's personality was gone. “He was a flat line,” said his mother, Martha Luttrell. Josh's long-time coach, Sam Pendleton, visited the second day — he was only allowed in because he pretended to be Josh's grandfather. Martha said she noticed Josh's face light up, and she knew having visitors would be important to his recovery.

When he was stabilized enough to move to a regular hospital room, doctors slowly started introducing stimulation, letting in a little light and a few visitors. When he was finally able to complete an MRI, Josh was sent home with 24-hour supervision. Someone visited every day for 28 days, which really helped, Martha said.

At first when Josh came home, even trying to sit up would make him feel nauseous, but after some physical therapy he could manage it. He got a wheelchair and eventually was also able to crawl. He would scoot down the stairs on his butt, and at night his parents would carry him back up, in a blanket, to his bed.

Josh's experience illustrates the extent to which an impact in sports can affect the delicate organ that controls almost everything related to how we experience life and act in the world. The Center for Disease Control estimates between 1.6 and 3.8 million sports-related concussions occur in the United States each year. Other leading scientists put that number higher. But until recently, impacts in sports were not taken seriously.

Now as evidence emerges that receiving multiple concussions can have long-term effects in some cases, the athletic community is paying more attention. It is crucial to manage concussions properly in young people because a second concussion can lead to second-impact syndrome, seen only in people college age or younger, which causes permanent neurological damage or death. In addition, caregivers must be alert to symptoms that can indicate a blood clot is causing pressure in the brain, like increasing confusion, neck pain, temporary loss of consciousness, or weakness or numbness in arms and legs.

Josh was monitored carefully throughout his recovery. Once he was able to handle the long ride, he went to see Dr. Michael J. O’Brien, director of the sports concussion clinic at Boston Children’s Hospital. O'Brien told him he would walk again, but he didn’t know when. In addition to his concussion, Josh had an extremely rare injury in which the part of the brain that connects to the spinal cord stretched to almost snapping, causing those neurons to shut down — a neuropraxia. At some point, O'Brien said, Josh would experience a "brain awakening," and would regain the ability to walk.

The awakening happened seven weeks after his injury. His mother had been rubbing his feet to help the circulation; they were always cold, she said, but that week they started to get warmer. At the beginning of the week, with physical therapy, he was able to raise and lower his legs again, and by the end of that week he could walk with a walker. The neuropraxia was over — but his concussion was not. By the next week he was able to return to school for short one-on-one tutoring sessions at the end of the day.

"The toughest thing about going back to school was [not] being able to keep track of things,” Josh said. “Math was definitely the hardest thing, and reading was hard. I could look at [the text] but I didn’t know what it meant. And I couldn’t look at screens. I had to do everything on paper.”

Martha said what are most difficult for concussion patients when they return to school are organization and concentration, affecting their performance in every subject. Josh was able to complete all the credits he needed his freshman year through tutoring, but only with major accommodations.

But he did get better. Now Josh is back in honors classes, and his lingering headaches, which lasted through the first year, are gone. He told the story of his ordeal with a relaxed humor, having put it all behind him. He’s playing soccer and basketball again and plans to try out for soccer in college.

“I’ve been playing soccer since I was 4 or 5,” he said. “I wouldn’t give it up.”

He plays a little differently now, though he still heads the ball, which makes his mother cringe.

“Now every time I find myself floating through the air,” he said, “I tuck into a somersault and roll.”

Midcoast concussion management resources

Josh may be able to attribute his full recovery to excellent care from his mother, accommodations at school, and the resources available in the Midcoast area. Dr. Kendra Bryant of Neuropsychology and Concussion Management Associates of Rockport, with whom Josh began working right away at the advice of athletic staff at his school, is considered by many the best in the state. Bryant studied with Dr. Micky Collins, director of the sports medicine concussion program at University of Pittsburgh and an international leader in concussion research. He co-wrote the Centers for Disease Control's guide for physicians on treating concussions and helped develop the ImPACT test, a computerized test used in evaluating how much a concussion has affected brain function. Bryant stays in contact with him to follow his research.

Martha Luttrell took an active role in her son's treatment, and volunteered at Bryant's office while he was a patient there. When he recovered, Bryant offered Martha a job as practice manager and patient liaison, the position she holds today.

The physical therapy Josh received from therapists Kelly Reynolds and Mark Lewis at Downeast Rehabilitation Associates in Rockport helped him return to sports. With Reynolds he regained the use of his legs and with Lewis he regained his center of balance and his endurance. Dr. Katie Snow of Snow Sport and Spine in Rockport provided craniosacral therapy, which helped reduce his headaches.

In addition to those resources, in September 2014, a new concussion management program opened at Waldo County General Hospital's Orthopedic & Sports Physical Therapy Center. Designed according to Bryant’s wish list of therapy resources for the region, the program offers ocular, vestibular and craniosacral therapy to help with issues with vision, balance and headaches. Therapists suggest modifications to patients' activities to help them return to their normal routines, and connect patients who may live alone or need assistance during their recovery with other resources in the community.

An often overlooked, misunderstood injury

Another reason Josh may have had such a successful recovery is that his neuropraxia made a typically invisible injury easy to detect and obvious to himself, school administrators and his peers, allowing him to get the right treatment, rest and accommodations right away and throughout his recovery. But that is not always the case with concussions.

Moriah Grant, an occupational therapist with WCGH's concussion management program and board member of the Maine Concussion Management Initiative, says there is a hidden epidemic of people walking around with undiagnosed concussions or lingering symptoms of concussions from which they haven't fully recovered.

Many people don't recognize the symptoms — which can include headaches, confusion, light sensitivity, fatigue, nausea, irritability and sadness — or realize that more than 90 percent of concussions do not involve a loss of consciousness. They are not necessarily caused by a blow to the head, but can be caused by an indirect impact.

In schools, athletic staff are well trained to recognize the signs of concussions, Grant said, but twice as many concussions occur to non-athletes, and those are less likely to be diagnosed. Often concussions are overlooked in people who show up in emergency rooms with other injuries; their symptoms may be misinterpreted as part of another injury or reactions to antibiotics, she said.

Beyond challenges in diagnosis, the invisible nature of the injury makes it more difficult for the patient and the people they interact with to give the brain the rest it needs to heal. With other injuries like a broken leg, the injured person is usually wearing a cast until a doctor determines it is ready to come off. It is easy to see there is a reason the patient is unable to move at normal speed. But with a brain injury, people may be less likely to attribute comprehension difficulties, slow response time, fatigue and other symptoms to the injury.

Martha Luttrell says a big problem for teenagers with concussions is that when faced with recommended workload reductions and classroom accommodations their teachers often wonder, "They're here, they're in my class, they're talking to their friends, why can't they do the work?" They may conclude the student is just being lazy and demand more of them than they are able to do.

Grant says sometimes concussion patients' friends tell them to "buck up" and get over it, as if they are interpreting their symptoms as character flaws. Patients themselves can become frustrated and depressed if they cannot keep up with their workload or their grades slip if they've returned to school too early, and they wonder why what was once easy for them has become difficult.

Josh said he was fighting depression during his recovery as he was effectively removed from his life. He would also sometimes experience what he referred to as a "snap," and would suddenly become very angry. When that happened, Martha said she would go upstairs, wait for it to pass — and cry. She knew his anger was caused by the concussion, but did not know if it was going to be a permanent part of his personality.

"Concussions tend to emphasize your strengths or weaknesses," Grant said. "And more often your weaknesses."

Advances in treatment

Although there is still uncertainty around what is happening in the brain during an impact and the long-term effects of concussions (see related article), there have been tremendous advancements in the treatment of head trauma — it has come a long way since "trepanning," removing a small piece of the injured's skull, was common practice. The typical modern approach to treating concussions is for the patient to rest in a dark room until the symptoms are gone a tall order for many because by resting, doctors mean doing nothing at all, not even looking at TV, computer, iPad or phone screens.

But patients are rarely able to do much at all anyway, and are often surprised at how exhausted they become when trying to perform simple tasks.  Grant said even washing dishes can bring about fatigue:

"When you have your hands in dishwater, you're feeling temperature, you're feeling wetness, you're standing up, there's a knife in there somewhere so you really should be paying attention, someone's talking to you or the radio's going, and you're trying to do all this at once. Break down that task into what the brain is doing — it's moving, it's feeling, it's seeing, it's smelling. You're forcing your brain to interpret too much."

She even tells patients to turn down the lights when eating spicy food, to prevent the brain from having to process too much.

For most concussions, a couple of weeks of absolute rest is all that is needed. Others involve complications that prolong recovery, but even those can be treated.

Bryant said complications can include visual dysfunction, where the eyes may have difficulty tracking or working together, or disruption of the vestibular function, the way the body detects where it is in space and what is moving around it. Both of those problems can cause dizziness, nausea and fatigue. Fortunately, there are modifications and exercises that can help improve those functions and reduce symptoms. Modifications like lowering the brightness of the computer screen, narrowing the working window and taking visual breaks can help reduce fatigue and headaches, allowing people to get back to work and school earlier.

Grant demonstrated some exercises that can help vestibular and visual functions recover. In one, she shifted her focus from one point in the room to another and another rapidly. In another, she stood with her eyes closed on a soft platform, then lifted one foot. Challenges in these exercises are increased as long as symptoms do not return.

“One of the key concepts in vestibular rehab is if you help your brain reorganize what your inner ear is telling you, your eyes will follow," she said. "Our other sense of balance is our eyes, not just our inner ear. When vestibular and ocular issues improve, the rest of the symptoms seem to as well.”

Craniosacral therapy can help realign the plates in the skull that may have moved with the impact. Martha Lutrell said this allows fluid to flow properly and reduces patients' headaches and feelings of fogginess. Josh received that treatment from Dr. Katie Snow.

“It was like a brain massage," he said. "She rubbed pressure points and opened up passageways."

Patients used to be restricted from physical activity completely until they were recovered and returned to school sooner, but now patients may be returned to physical activity within one or two weeks with a gradual and methodical protocol, before they return fully to cognitive activity.

"It turns out physical activity is actually good for people in their recovery early on," Bryant said. It is also a way to combat the depression that can accompany the absolute rest that is required to let the brain heal.

Scientists have also recently identified some pre-existing factors, including anxiety, a history of migraines or migraines in the family, and ADHD, that can indicate that someone will have a longer or more complicated recovery. By identifying those factors early on, they can begin treating those patients differently right away.

Bryant said there are very few concussions that last more than six months. Some neurologists call patients whose symptoms do last longer the "miserable minority," and suggest they are faking at that point because there is no mechanism to cause continued symptoms. But she says in most of those cases, there is vestibular or visual dysfunction involved, and in others there may be underlying issues of which the patient may not be aware. For example, the patient may have an aversion to returning to a negative situation at work. Once those issues are worked through, the symptoms usually subside.

Amid all the uncertainty around concussions and their effects, the difficulties of diagnosis and detection, the physical and emotional struggles of students and athletes suffering from concussions, the dangers of second-impact syndrome, and the promising developments in treatment, Maine public schools have been charged with adopting concussion management policies. LD 1873, passed in 2012, required schools to begin implementing the policies by Jan. 1, 2013.

Part 2 of this investigation will look at how area schools are implementing the new policies and minimizing risks for students with concussions.