In 2013, Ann Marie Woodruff was involved in a severe traffic accident that crushed her skull. Eight years later, her ongoing path of recovery took a new twist when she had a seizure and was diagnosed with epilepsy.

November is Epilepsy Awareness Month, a time to highlight the disorder that happens when the brain’s electrical activity misfires – a seizure. People with a traumatic brain injury (TBI) are at higher risk for developing epilepsy weeks or sometimes years after their brain injury, as in Ann Marie’s case. 

Ann Marie was 7 years old when she was involved in the wreck. The trauma to her brain caused serious complications:

• Removal of forehead bone, to give space for her injured brain to swell
• Reconstruction of her forehead with a titanium plate  
• Physical, speech and occupational therapy during three months of hospitalization
• Problems with reading comprehension, headaches and noise sensitivity
• Then at age 16 … the epilepsy diagnosis

Despite all those challenges, the Euless 18-year-old is now a high school graduate and a licensed driver. She’s following her dream by working at a kennel and attending dog grooming school. The anti-seizure medication she takes causes some sleepiness but has kept her epilepsy under control.  

"Epilepsy stumped us for a few months, but she is such a determined girl that she was not going to let epilepsy keep her down or define who she is or wants to be," said her mother, Carla Woodruff.

According to the Epilepsy Foundation, seizures can result from a change in the chemical environment around the brain cells after bruising/bleeding in the brain, or a skull fracture. Early treatment with medication reduces the chance of additional seizures.

Ann Marie fits the higher-risk category for developing epilepsy because she lost some tissue in the frontal lobe of her brain, said Cook Children’s neurology nurse practitioner Erin Davis, APRN, CPNP. Ann Marie sees Davis every six months to manage her epilepsy. When she meets with families in neurology, Davis uses the analogy of file cabinets to explain how the brain stores memories and other functions. 

“It’s all organized,” she said. “And when you have a traumatic brain injury, they all get knocked over. You have to spend time lifting each one back up and then putting the files back in.”  

Ann Marie has come a long way in putting those file cabinets upright thanks to perseverance, a sense of humor, and the skill of her providers at Cook Children’s. “I have spent the last 10 years doing so many things to improve myself and not just be the girl with a brain injury,” she said. “It hasn’t been easy. But I know I’m worth it.”

This is her story.

The Injury

In the second grade, Ann Marie lived in the West Texas town of Anson. She took karate class in Abilene, about 25 miles away. Her dad, Bill Woodruff, picked her up from karate on Jan. 29, 2013, and began driving home. Ann Marie sat in the back buckled into a high-back booster seat. It was dark and dusty, which reduced visibility on the highway.

Bill Woodruff didn’t see the stopped 18-wheeler that was blocking both lanes. Their crew cab truck slammed into the semi’s trailer and went under it. The impact killed Ann Marie’s dad. She took a blow above her right eye, and her skull was shattered.

Paramedics rushed Ann Marie to a hospital in Abilene. She had multiple injuries – including a liver laceration and broken leg -- but the most urgent priority was to relieve pressure from the swelling of her brain. Doctors in Abilene performed a craniectomy, removing most of her forehead bone from ear to ear. Later that night a helicopter transported Ann Marie to Cook Children’s Medical Center in Fort Worth.     

Admitted to the pediatric intensive care unit, she remained in a coma for several weeks. Therapy began once she woke up.

“She had to relearn everything … how to walk, how to talk, who she was,” Carla Woodruff said.

Ann Marie’s brain shifted as the swelling and fluid began to subside. Measurements were made via CT scan, and a manufacturer in Germany created a metal device to fit the exact size and shape of her missing bone.

In the meantime, Ann Marie wore a hardshell helmet to protect her head in case she fell or something bumped into her. The next step: Placing a titanium plate across the gap in her forehead.  

Reconstructive Surgery and Therapy

Seven weeks after the accident, Ann Marie went back into surgery for a cranioplasty, to replace the missing part of her skull. Cook Children’s neurosurgeon Richard Roberts, M.D. followed the incision made when the bone was taken out. Peeling back the skin was a slow process because her scalp was so thin.

Dr. Roberts installed a plate custom-made for Ann Marie and built from titanium, which resists infection. The plate contains hundreds of tiny holes.

“What winds up happening is tissue from underneath and tissue from the scalp can grow together through the holes and help anchor the plate,” he said.  

He described Ann Marie’s recovery as amazing given the extent of her injury.

“If you look at the original CT scan you would think it would be difficult to survive,” Dr. Roberts said. “The hard work and dedication of Ann Marie and her mom and the whole hospital laid the foundation for success.”

That hard work included speech, physical and occupational therapy during her stay at Cook Children’s. As a nurse practitioner, Davis coordinated various aspects of her care. Exercises were designed to feel like play. Those sessions aimed to repair Ann Marie’s attention span, impulse control and other thought processes. For patients with TBIs, intensive rehabilitation soon after injury can help the brain to rewire, Davis pointed out.  

Speech therapy six days a week helped Ann Marie to regain language, focus, and skills such as problem-solving. Speech pathologist Renee Lavelle, MS, CC, SLP in the Neuro Rehab Unit helped Ann Marie learn to eat, starting with liquids and moving to solid foods. “She was easy to work with. She would try anything,” Lavelle said.

Ann Marie remembers little about being hospitalized. But she does recall feeling feisty enough to warn the nurses that she knew karate.

When she was discharged three months after arriving at Cook Children’s, Ann Marie could walk with assistance, feed and dress herself, and respond to simple questions. She continued speech therapy on an outpatient basis and returned to Cook Children’s for annual checkups.

“Over the years every time I see her, she’s better and better,” Davis said. 

Adapting and Achievements

The mental fog continued to lift after Ann Marie left the hospital. But reading comprehension remained a particular struggle. She eventually enrolled in Novus Academy in Grapevine, which serves students with learning differences. She made good grades and thrived in the alternative setting, graduating in May 2023.

It takes a little longer for the pathways of Ann Marie’s brain to process information.

“When asked a question, I usually can’t just answer. I must think about it and see if my brain has stored it somewhere,” she said. “It isn’t always there.”

But she has found new tricks for learning, especially through touch and music. She took up the piano, guitar and trombone. She also loves caring for animals. Her mom describes Ann Marie as kindhearted and hardworking. And she’s resilient when challenges arise, like the news that she needed medication for epilepsy.  

As Ann Marie puts it … Being stubborn comes in handy. Don’t let hurdles stop you from pursuing your goals, she advises. She hopes to someday work at a zoo or wildlife refuge.

“Sometimes it takes a little more grit, but you can do it,” she said. “Don’t give up on your dreams just because something is hard. It is worth everything you must put into it.”

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At Cook Children’s SPORTS Rehab, we’ve noticed a shift in what we see in our clinic. Over the past decade, the three major changes we’ve seen are the number of overuse injuries, the amount of early sports specialization and the way we treat concussions.

The first two issues I mentioned go hand-in-hand. It’s no coincidence that we are seeing more overuse injuries at the same time we are seeing early sports specialization. Overuse injuries come from repetitive micro-trauma to tendons, bones, and joints caused by repeating the same type of activity over and over.

If kids are playing the same sport all year around they are repeating the same movement patterns over and over again. Growing up in the 1980s and 1990s there wasn’t the opportunity to play year round sports like there is now. You may have had a favorite sport, but you had to wait for that season to roll around, and in the mean time you would play another sport if you wanted to stay active.

Now, if your favorite sport is baseball, you can find leagues to play in all year round, and the same is true for most other sports. As a result of this early specialization, we are seeing more and more overuse injuries in our young athletes.

In our baseball and softball players we are seeing more elbow and shoulder injuries, and the number one risk factor for overuse injuries of the shoulder and elbow is the volume of throws. If an athlete is playing baseball year round, the volume of throws is going to be significantly greater than an athlete that takes a break to play another sport.

A recent study showed that 15-19 year olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions (Tommy John) performed between 2007-2011.This means over half of these surgeries are being performed on patients who haven’t even finished their freshman year of college. While early specialization is a contributor to the uptick in these overuse injuries it is not the only factor. Things like poor mechanics, poor flexibility and inadequate strength all contribute to overuse injuries. As more and more kids participate in athletics there becomes more and more need for good conditioning and injury prevention programs. Increased sports participation is a great problem to have, because that means our kids are being active, but it also increases the need for our coaches, and we as parents, to be more aware of ways to keep our kids safe from these overuse injuries.

Treatment of concussion has been a popular topic in the news as of late, and this is an area that has changed significantly over the last decade and continues to evolve as we learn more about these injuries. Ten years ago we tried to grade concussions based on the severity. The concussions were graded 1-3 based on the patient’s symptoms and whether they lost consciousness. In some cases of Grade 1 concussions, the athlete was allowed to return to activities the same day as the injury.

We then switched to saying the athlete either has a concussion or they don’t, and all athletes that were deemed to have a concussion were disqualified from participation until cleared by a physician. In most cases we would shut these athletes down completely; limiting TV, school, phone time and interaction with other people in an attempt to let them get complete cognitive rest until their symptoms resolved. Then once symptoms resolved we would start a return to school and return to play protocol.

Now kids still have to be cleared by a physician, and they still have to follow a return to play protocol, but we have realized that completely isolating these kids while they recover and limiting their interaction with friends was doing more harm than good.

So after a brief period of brain rest (approximately three days), we start slowly integrating kids back into activities of daily life as tolerated. It is important to have a physician that deals with concussions involved in the patients return to activity so that they are getting the appropriate accommodations at school and home to allow for the appropriate amount of rest, but that will still allow enough activity to stimulate the patient enough to promote recovery and keep them from becoming isolated.

For more on the specifics of how treatments have changed for all of these areas, and for information on other changes in sports medicine, we would love for you to attend our annual Cook Children’s Sports Medicine Symposium July 21, 2016.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annualSPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

He’s not hurt and had a presumably bright future in the NFL.

Why did he retire?

In light of the recent focus on repetitive trauma, concussion and brain injury, he decided that it was in his best interest to stop playing football.

Consider it this way: After years of playing football, starting a very young age, succeeding in high school and later at the University of Wisconsin, he reached the pinnacle of his sport and decided it was better to walk away than to keep playing. Granted, he’s only one player and many, many more will continue to make the decision to go back to training camp in July.

Most football players will never reach that point where they’ll have to decide if the NFL is right for them. I played junior high football, but didn’t move on to high school. I like to tell myself that I was making sure I was protected from injury for tennis season (truth was, I was probably a little scared of being small and getting hit by bigger high school kids. Sorry for lying, Coach West).

If you look at the research,  it seems like cumulative trauma is the issue. The older and bigger you get and the longer you play, the number and the force of the traumas increase. The rules are changing in an attempt to make the sport safer. But, I’m sure many of you read this and worry about your young football players.

My sons haven’t asked to play football yet. At 5 and 3, I think the level of risk for concussion is higher when I pick them up and throw them as high as I can in the air barely grabbing them before they crash into the ground. But living in the middle of Texas, football countr,y and having an older son built like a perfect tight end and having little brother with a canon for an arm, I am sure that is a conversation we will have some day.

I wonder if someday we’ll look back on the days when football was played and think, “I can’t believe that they used to do that to themselves.” Or, will the sport look so different that we will barely recognize it?

What about you? Do you have concerns about your sons playing football?