The Gary Galiher Law Hour — Episode 11: Making Sports Safer for Kids w/ Sam Lee

We all know what can happen from a single, huge traumatic event like a car crash, or getting your bell rung at a football game, where you have a more life-threatening injury. Less obvious, though, is what goes on throughout a multi-year span of activities by an athlete: they have a cumulative effect that can be as bad as a single, major trauma.

Athletes of all ages who play contact sports take sub-concussive injuries in their day-to-day play. “What’s really happening in the brain when they’re children, especially young children, in these sub-concussive injuries, is the same cascade of chemicals, the same repair mechanisms happen that happen during concussions—it’s just that they’re happening a lot more frequently,” said Gary Galiher, our founding partner.

Researchers in the field of neurotrauma are very aware of this, but we want to see people everywhere begin to understand that many of the sports our children play could have serious negative effects on their cognitive abilities down the road.

Our firm is all for sports—including football—but when children as young as seven or eight years old are playing full-contact and sustaining head injuries, we know that something is wrong. It’s necessary to change how our children are playing, the conversation about how to make these changes needs to begin right away, and it cannot be informed just by what the NFL wants us to know.

We are moving that conversation forward with today’s guest, Sam Lee, an award-winning (and very charismatic!) athletic trainer at Hawai‘i Baptist Academy in Honolulu. He was the recipient of the 2015 District 8 Gatorade Secondary School Athletic Trainer Award, for establishing a concussion management program at his school, as well as helping the Hawai‘i athletic association develop comprehensive heat acclimatization and practice schedule guidelines.

Our talk with Coach Lee covers the vital angles of the issues mentioned here, from the state of things today to the future of student athletics. Tune in and find out why Hawai‘i is a progressive state in the nationwide battle to make sports safer for young people.

The Gary Galiher Law Hour — Episode 10: Sub-Concussions and CTE w/ Dr. Violet Horvath

It’s not just NFL pro players who have to worry about concussive and repetitive sub-concussive injuries. Kids who play sports are being exposed to these traumas, too.

Dr. Violet Horvath, Director of the Pacific Disabilities Center, along with our very own Anthony Carr, joined our host Mike Buck for today’s episode of the Gary Galiher Law Hour. Their conversation helps sheds light on the risks of these injuries and how to decrease them.

Evidence of the connection between chronic traumatic encephalopathy and behavioral changes is mounting. Several researchers at the Neuro-Huddle said they believe CTE to be at the root of the mood instability and unhinged behavior often seen in the victims.

Hard proof of this remains to be established, however, because the science of CTE is still nascent. While we learned a lot at this year’s Neuro-Huddle and CTE Conference, according to Dr. Horvath, “it was clear. What we don’t know far exceeds what we do know.”

For example, there’s no way to diagnose with certainty whether a living person has CTE. Studies aimed toward making diagnosis possible are underway now, and those leading it hope for results within the next year or two.

Meanwhile, there are huge opportunities for the prevention of head injuries. Dr. Horvath recommends that young people not play football, soccer or judo, which carry high risks of head injuries. Again, the current understanding of brain science is insufficient: “With the kids… some of the things that are being proposed are that no one under 12 be able to do any kind of contact sports, at least in football, and honestly 12 is kind of arbitrary. We don’t know. Maybe it needs to be 9, maybe higher is okay,” she said.

Another issue is that people this young aren’t able to give informed consent. They’re generally too young to fully understand the issues, therefore they cannot make decisions about playing that could affect them decades into the future. “Until someone is actually old enough to understand and give their consent for themselves, maybe they shouldn’t be playing.”

If you are a resident of Hawai‘i of any age who has had a traumatic brain injury or concussion, stroke, or spinal cord injury, Dr. Horvath would like to ask for a few minutes of your time to participate in the Hawai‘i Neurotrauma Registry Project Online Survey. Find more information about it and join the registry at the Hawai‘i Neurotrauma Registry website, and take the Hawai‘i Neurotrama Registry Survey here on SurveyMonkey.

As always, thanks for tuning in!


Photo: Boston University Center for the Study of Traumatic Encephalopathy, “Image of chronic traumatic encephalopathy“, (c) CC-SA-4.0

It’s National Brain Injury Awareness Day

This month is Brain Injury Awareness Month, and today, March 16th, is National Brain Injury Awareness Day. Our friends at the Brain Injury Association of America (BIAA) are on Capitol Hill, advocating for increased civilian and military access to care, funding for state programs, expanded brain injury research, and raising congressional awareness of brain injury-related issues.

national-brain-injury-awareness-dayThe co-chairs of the Congressional Brain Injury Task Force hosted a brain injury awareness fair with over 50 exhibitors, a congressional briefing, and a reception to celebrate the Congressional Brain Injury Task Force and Brain Injury Awareness Month.

Brain injuries have a great cost to society: they claim the lives of 137 people every day, and affect someone in the US every 13 seconds. The Centers for Disease Control and Prevention estimates that 1.7 million people sustain a traumatic brain injury every year in the US. According to Daniel Weinberger, MD, director and CEO of the Lieber Institute for Brain Development at the Johns Hopkins School of Medicine and Professor of Psychiatry, Neurology, Neuroscience and Human Genetics, brain injury is the “leading cause of long-term disability in children and adults younger than 35 years, costing $75 billion a year.”

Despite these astounding rates of incidence, brain injury has gotten little recognition around the US until recently, and even now remains largely ignored outside of its role in American football. For example, few people seem to know the extent of the TBI problem in the military, but over 339,000 military service members have been diagnosed with a TBI since the year 2000. We at Galiher DeRobertis & Waxman would like to see the conversation broaden so that TBI can no longer be called a silent epidemic.

Most of the public discourse and scientific research to date has focused on the pathology and prevention of traumatic brain injury (TBI). Though these efforts are very important, there is also a great need for the development of new treatments for people who have suffered a TBI, not only through understanding the damage done to the brain but, more importantly, through learning how to improve function of the parts of the brain that remain undamaged.

We at the firm have put a big effort into raising awareness of TBI and concussions (which are a particular form of TBI) in Hawai‘i, so we are glad to see issue of traumatic brain injury under the national spotlight again. However, we still have more work ahead to increase the prevention and awareness of brain injury. The Galiher firm aims to: help individuals and families affected gain financial stability after sports-related brain injuries, and to protect the brains of our young athletes so that children can participate in sports without risking serious injury.

Learn more about TBI and visit our knowledge center at

CTE Conference 2016 Wrap-Up

We hosted quite the conference, last week. The CTE Conference 2016 brought together leading researchers and practitioners, to share the latest research related to chronic traumatic encephalopathy (or CTE for short), traumatic brain injuries (TBI), and sports safety.

Click here to view the video at Hawai‘i News Now – KGMB and KHNL

The second day of the conference was the second annual Neuro-Huddle. Its focus was on the long term impacts of concussion, sports safety, with the intention of developing public awareness of CTE in sports related trauma and injuries.

CTE and concussions in general are quite the hot topics. In a recent poll by HBO Real Sports/Marist, roughly one third of Americans have have become more concerned because of the link between concussions suffered while playing football and long-term brain injury. A similar number said they would be less likely to allow a son to play the sport because of the head-injury risks.

Just in the last couple days of news, we’ve seen a New York Times exposé on the NFL’s surprising growth in spite of growing concern over concussion and degenerative brain diseases, in “Roger Goodell’s Unstoppable Football Machine.” Another nationally published piece came from Congressman Jim Jordan, vowing to improve youth sports through health and safety initiatives as co-chair of the Congressional Caucus on Youth Sports.

Though football is but one among many contact sports, it gets the spotlight in these discussions, given its status as a national obsession and as the sport with the second-highest rate of concussions (after girls’ judo).

It was an honor to be joined during the conference by some of the most credible researchers in the fields of athletic training, neuropsychology, pathology and sports medicine. Our speakers generously shared the latest insights and research in their areas of expertise. We recorded the event, and we’ll be rolling out the highlights on our blog over the rest of the month. There’s so much to share. Stay tuned!


Brain Injuries in Youth Athletics

Scientific advancements and a greater understanding of the issues that affect the health and safety of young athletes are key to reducing sports-related concussions in youth, reads Congress’s Youth Sports Concussion Act of 2013. States across the country have been quick to respond to the challenge of preventing student athlete injuries through implementing concussion management policy.

Why is this important challenge only beginning to be addressed? Previously, a concussion was assumed to happen only if a person fully lost consciousness. It turns out that experiencing a concussion or mild traumatic brain injury (mTBI) is more common than previously understood. In 2010, about 2.5 million emergency department (ED) visits; hospitalizations, or deaths were associated with TBI in the United States. Many of these injuries occur during participation in youth athletics – particularly sports such as football, soccer, basketball, judo or even cheerleading. Sports and recreational activities contribute to about 21 percent of all traumatic brain injuries among American children and adolescents (CDC).

Given the data available on mTBI, the actual incidence of injuries may potentially be higher than reported. Many less severe head injuries are treated at physician’s offices or immediate care centers, or are self-treated.

Defining Brain Injuries

The International Conference on Concussion in Sport held in Zurich, Switzerland brings leading neuroscientists from around the world to discuss and define “concussion,” a subset of mTBI. Referred to as the Zurich Guidelines, the report is one of the cornerstone references for diagnosis and management. In 2012, during their 4th annual conference, they published the following definition of a concussion or mild traumatic brain injury:

Concussion is the historical term representing low velocity injuries that cause brain ‘shaking’ resulting in clinical symptoms that are not necessarily related to a pathological injury.

“It is a brain injury defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include:

  1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.
  2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
  3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural
 injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.”
ouchTaking Action to Minimize Risk

The definition, diagnosis and treatment of the concussion still face significant challenges and controversy. Scientists are studying potential leads for biomarkers – ways to determine through changes in body chemistry whether or not an individual has had a mTBI. Other than diagnostic specificity, development will also need to be made in evidence-based management strategies and rehabilitation.

As the awareness around the dangers of unnoticed or mistreated brain injuries in youth athletics increases, researchers and policymakers are working to minimize the risks of participation in sports. In 2014, the White House held the first Healthy Kids and Safe Sports Concussion Summit focused on advancing research on sports-related youth concussions and raising awareness of steps to prevent, identify and respond to concussions in young people. All states have some degree of concussion policy. State-mandated management programs ensure that schools and extramural athletics organizations have all the resources to treat brain injuries in a manner consistent with the most up-to-date medical understanding.

Further Resources for Parents and Athletes

When facing the difficult decisions of what to do after a traumatic brain injury, it is important to have the best information possible. A mild brain injury or whiplash could still contribute to long-term behavior and learning impediments. The period of recovery after the injury is critical, and in some cases may even require a multidisciplinary medical team. Those who are closest to the injured athlete such as parents, teachers, coaches teammates and friends will also be critical in a speedy recovery, since brain injuries are not as obvious as broken bones or other physical injuries.

1280px-US_CDC_logo.svgCheck out the “Fact Sheet for Parents”, and other free resources from the CDC’s HEADS UP to Youth Sports program:

Mild Traumatic Brain Injury Is an Oxymoron

Above: The connective neurons of the brain are stained green by an antibody to SNTF, which is a protein that could soon be used to detect concussive injuries.

New Protein Biomarker Highlights Damaged Brain Wiring After Concussion, Finds Penn Study

The link between concussions (also known as mild traumatic brain injuries) and long-term brain damage was further proven last month. Researchers from the University of Pennsylvania and the University of Glasgow released a study in Acta Neuropathologica, demonstrating their connection. The researchers found that when concussions occur, a brain protein called SNTF can increase in the bloodstream. Its presence indicates a type of damage believed to be a source of long-term cognitive impairments.

The type of damage to nerve fibers indicated by SNTF is known as diffuse axonal injury. According to the senior author of the study, “our findings also confirm that even relatively mild, concussion-type brain impacts can cause permanent damage of this kind.”

“Traumatic brain injury (TBI) is the chief cause of death and disability among children and adults from 1 to 44 years of age in the United States, leading to more than two million emergency department visits annually,” according to UPenn’s press release. So-called mild TBI or concussions make up the vast majority of these injuries, which go unrecognized and untreated all too often. Recent studies suggest that one in five patients with such “mild” injuries suffer from impaired cognition for at least several months, often longer.

The mechanism of this injury had been shrouded in mystery, because concussed brains show no detectable evidence of trauma on standard CT or MRI scans. Under a microscope, however, brain tissue from severe cases of these injuries exhibits “swollen, degenerating, and even fully disconnected axons throughout the white matter.” In diffuse axonal injury, bundles of axons that connect regions of the brain stretch and shear. Investigators believe that some axons, unable to recover from the damage of a concussion, trigger a self-destruct process that fully severs the nerve fiber from the brain, never to be restored.

Simple Blood Test Could Inform Head Injury-Related “Return to Play” Decisions

Earlier work in the field has shown SNTF to be a tell-tale sign of axon destruction, created as a byproduct thereof. In the first several days following a TBI, new studies have found SNTF levels to rise more in those who suffered greater cognitive impairment.

This new study aimed to prove SNTF in particular as a marker of axonal injury. The study found that SNTF, which is undetectable in healthy brains, “predominantly identified only injured axons.” If further research pans this out further, it may soon lead to the creation of a new test for concussion, much in the way blood tests indicate damage caused by heart attacks.

Towards that end, doctors from the University of Gothenburg, Sweden, put this theory to the test in another research effort published last week. They found that blood SNTF concentration increased between 1 and 144 hours from the time of injury in professional hockey players who experienced persisting post-concussion symptoms.


Image: “Alpha II-spectrin N-terminal Fragment”, EnCor Biotechnology, Inc.,, Creative Commons Share-Alike 3.0 license

Jamie Higa’s Story

Jamie Higa was on her college basketball team when she suffered her fourth concussion.

Recovery has taken years. Her coach “did not take injuries seriously,” and pressured her team to play through any pain. Concussions, Jamie learned, belong in a very different category of injury. The following is the story in her own words.

jamie-higaIn December of 2011, I suffered my fourth concussion while playing basketball for a university. I’ve been through my fair share of injuries including sprained ankles, sprained fingers, stitches, and have fractured a wrist, thumb, and leg. I was at the orthopedic doctor so much that we had inside jokes by the time he was taking off my second cast. Needless to say I understand pain, I understand injuries, and am familiar with rest and rehabilitation; but rehabilitating a concussion has been the most excruciating recovery yet.

Suffering from a concussion is not the type of injury that athletes are accustomed to. You do not feel agonizing pain like you do when you’ve fractured your shin in three places and have to be carried off the court. Instead when you report symptoms to the athletic trainer you find yourself saying, “my head feels weird” or “the lights are bothering me.” If athletes are expected to be mentally and physically tough, how are we supposed to ask to come out of a game because of a headache?

The coach I was playing for did not take injuries seriously. He would tell us, “I don’t care if your arm is broken, because your legs still work and you can run down the court.” He even went as far as saying “even if your eye is falling out, you still have another that you can see out of!” So when I was hit from behind, causing me to fall forward, and hit the front of my head against the court, I could not find it in me to admit I was injured. I did not want to admit it to my teammates, athletic trainer, coach or even myself. I was afraid of speaking up.

After the night of my injury things only got worse. My symptoms were persistent. I had headaches, migraines, light sensitivity, motion sensitivity, dizziness, nausea, trouble sleeping, fatigue, and eye disturbances. After having to withdraw from school I flew to Pittsburgh to get treatment. At this point I was a year into the concussion and the road to “normalcy” was only beginning. My days were consumed with vestibular, ocular, and exertion therapy as well as three different medications.

Countless doctors’ appointments and hours of rehab later, I have reached my new normal. I still feel lasting effects from the concussion that include nystagmus (rapid involuntary movements of the eyes), headaches, occasional migraines, and balance problems. This concussion consumed my life and affected not only me, but the ones closest to me as well. I hope that through my experiences dealing with this injury it can help to change the stigma of concussions. If coaches and parents do not take this injury seriously, how can we expect athletes to? If they do not encourage athletes to report injuries, how can we trust our athletes to do so? We have the power to make the culture of sports a culture revolving around athlete safety, thus ensuring our athletes a healthy life after sports.

The Gary Galiher Law Hour — Episode 4: Football and Athlete Safety w/ Ross Oshiro

Last week, we started talking about how important it is for people—especially young people—to avoid the pitfalls of sports concussions. We continue the conversation this week with a special guest: Ross Oshiro, Coordinator for the Sports Medicine Program at the Queen’s Center for Sports Medicine joins us.

Chronic Traumatic Encephalopathy (CTE) is a brain disease caused by repeated hits to the head. Even sub-concussive hits that do not cause concussive symptoms increase the risk.

The aftermath of CTE is devastating, and even in the young brains of student athletes, it causes significant cognitive impairment. These students suffer both inside and outside of the classroom from memory loss and executive dysfunction (which is characterized by “deficiencies in planning, abstract thinking, flexibility and behavioral control“), which are brought on both by concussive injuries and CTE.

Football’s huge popularity and high concussion rate, combined with our new understanding of mild traumatic brain injuries, has made the sport quite the hot topic and subject of controversy, recently. Part of the reason football is so dangerous is because of the false sense of security that the helmets give the players. With such a hard shell, players could be excused for feeling invincible. But in fact, while these helmets prevent injuries such as skull fractures, they do little to prevent the less obvious trauma to the brain that concussive and sub-concussive hits cause.

The Big Question is: How can we save the coconut and keep football exciting? Tune in and learn about the technological, cultural, and financial dimensions of this complex issue; and about Hawai‘i’s leadership in advancing athlete safety in the sport of football.

The Gary Galiher Law Hour — Episode 3: Concussion Safety w/ Dr. Nathan Murata

In this episode, Team Galiher joins up with Nathan Murata, PhD., who is the current chair of the University of Hawai‘i Kinesiology and Rehabilitation Science Department, to discuss the cognitive as well as the physical aspects of sports concussions. Dr. Murata’s department has spent the last five years working with HCAMP and the Queen’s Hospital, as well as the many trainers in Hawai‘i public schools, to prevent concussions in various sports.

It’s Time to Change the Game

The conversation covers sports issues such as the National Football League’s cover-up of concussion issues, the sport with the highest concussion rate (wahine judo), and changes in the rules of sports that research into sports-related brain injury shows we need.

What’s important now for the athletes to realize is that there are safer methods of participation, but it also stems from the coaches and the coaching techniques that are currently being delivered in the schools.

—Dr. Nathan Murata, University of Hawai‘i at Mānoa

Hawai‘i is the only state in the US to require athletic trainers in all public high-schools, which is an important first step towards improving the safety of young athletes here. There remains room for improvement, however, in our treatment of the concussions that do occur, such as by ensuring athletes get adequate time for “cognitive rest,” during which the brain heals after a mild injury.

Concussion Prevention Is Still the Key

Moreover, preventing more concussions and sub-concussive injuries would make athletes safer still. Doing so will require changes to the way we play sports. People commonly overestimate the safety that helmets provide, and the NFL’s cover-up of and silence about the issues have curtailed efforts to change the game to make it safer.

We are seeing the tides turn, now, and state legislators are coming aboard. “We’re in a position where we’ve got a lot of people on the bandwagon, and we’re wanting to keep moving the bandwagon forward,” says Dr. Murata. “We plan to do so the best we can so we can continue to operate HCAMP on a state-wide basis, and in particular, not only the high-school student athletes but also the youth sports programs.”

HCAMP was embraced early on, and now all coaches and even some parents are required to go through concussion safety and informational training.

CTE at the Pro Football Hall of Fame

The annual Pro Football Hall of Fame convened on August 8th to honor the inductees:

Ron Wolf, former Green Bay Packers general manager
Charles Haley, former defensive end with the 49ers and Cowboys
Mick Tingelhoff, former center with the Vikings
Will Shields, former offensive guard with the Chiefs
Bill Polian, former general manager for the Bills, Panther and Colts
Tim Brown, former receiver with the Raiders
Junior Seau, former linebacker with the Chargers, Dolphins and Patriots
Jerome Bettis, former running back with the Steelers and Rams

While most of the inductees were able to receive their awards and deliver their thank-you speeches, Junior Seau was the only one among the group to be honored posthumously.

A controversy sparked when his daughter, wishing to give a loving speech about her father’s athleticism and personal values, was banned from speaking at the ceremony.  Seau’s early death at 45 and his struggle with neuropsychological issues relating to CTE caused trauma among his loyal fans and family.  Deciding to opt out of the NFL concussion lawsuit, the Seau estate is in the middle of a wrongful-death lawsuit against the NFL independently.

With the NFL as the main financial backer of the Pro Football Hall of Fame, the media speculated it was a convenient way to prevent the Seau family from potentially discussing the long-term neurodegenerative effects football has on players. The Pro Football Hall of Fame cited a policy enacted in 2010 that denied families of deceased honorees from speaking.

In the end, the Pro Football Hall of Fame decided to let Sydney Seau give a short interview about her father. She did not mention brain injury either on stage, or during a recording of her full speech by the New York Times. (Watch the full NYT video here.)

Between 2007 and 2015, Vice journalist Patrick Hruby points out, 31 members of the Hall of Fame died. Six of them were diagnosed with CTE, according to reports from the Sports Legacy Institute, a Boston-based nonprofit that studies sports-related concussions and brain trauma. Another 9 were diagnosed with dementia or Alzheimer’s disease, according to the obituaries.

Hruby ran the math, and made a shocking discovery. For every five Hall of Fame players to sit down at the same banquet table this weekend, one of them is likely to end up with CTE. (Read Hruby’s Vice article here.)