Category: Concussions in children
Use of Modified Acute Concussion Evaluation Tools in the Emergency Department in a Pediatric Population
Posted 1 October 2014 by prehab
In the pediatric population, mild traumatic brain injuries (concussions) make up 75%-90% of all acquired brain injuries evaluated in emergency departments (ER) in the US. The Acute Concussion Evaluation (ACE) system published by the Centers for Disease Control and Prevention was developed to assist in identification and diagnosis of concussions. The ACE Care Plan tool was developed to guide management, including individualized recommendations for daily life, school, work and return to play. This tool was originally felt to be too time consuming for ER physicians. For this study a modified version was created and preformed on a patient population between ages 5-21. A primary concern of post ED management of concussions was the importance of ongoing outpatient rehabilitation, in this study it was found that this tool improved reported follow-up post-implementation for all patients. It also found an improvement in parent recall of concussion education. For full study.
Posted 6 August 2014 by prehab
As the impact of concussions become more known in sports a major factor to look at has been time to return to sport. The researchers at the Sports Injury Prevention Research Center of University of Calgary looked at the effects of rehabilitating the cervical spine and vestibular system in a cohort of post-concussed athletes between the ages of 12-30 and the amount of time until they were medically cleared to return to sport. 18 males and 13 females were randomized between the control group and the intervention group. The intervention group received cervical spine and vestibular rehabilitation for 8-weeks or until they were medically cleared. Of the patients receiving therapy 73% were medically cleared to return to their sport in 8 weeks compared to only 4% of the control group. An article discussing this study was written in the Globe and Mail or See original study
Posted 2 February 2014 by prehab
Returning an athlete to the game should imply that who ever made the decision fully understands the nuances of the concussion.
There are many ways we collect quantitative information that gets us closer to understanding the areas affected after brain injury. The information however needs to be interpreted and understood well to determine the type of rehabilitation that well assists injured individuals on returning their brain to pre injury state. In this attached manuscript, we are reviewing the state of concussion testing, diagnostic rating scales and tools available to identify the nuances of concussions. At Concussion Management of New York we are clinician rather than test centered. We utilize these tools collectively or individually when most appropriate.
Posted 22 November 2013 by prehab
Abnormal brain structural patterns persist months after clinical symptoms had resolved from a mild concussion researchers found at the Lovelace Biomedical and Environmental Research Institute in Albuquerque, N.M.
Dr. Mayer and colleagues examined the underlying pathophysiology of mild traumatic brain injury through changes in gray matter diffusion and atrophy during the semiacute stage and found evidence that structural changes persist long past the improvement in neuropsychological tests. In a study that involved 50 participants, 26 patients showed evidence of increased cortical gray matter anisotropic diffusion 4 months post injury.
Posted 17 November 2013 by prehab
Family history of migraines is a precursor to headaches in children and as per studies cited bellow, head trauma and concussions may increase the length of headaches and complicate treatment. The question is: are Traumatic-Triggered Migraines (TTM’s) different than headaches as a concussive characteristic? and should they be treated differently? The case study referenced by Lords, Q reported in Sports Health Multidisciplinary App.(Traumatic Migraine Versus Concussion: A Case Report.) presented a different look at their diagnosis and treatment approach. This report instead of actually separating them apart it may be pointing out how related they are or that one is part of the other. Headaches post injury may be more or less severe, longer lasting and have a genetic component but should be dealt with in the contest of brain injury. The word “Concussion” can at this time, after it became a popular word in sports, complicate how we deal with it. Because concussions have the sports connotation is easy to fall into the trap of making us follow the light path others have taken and skip important steps toward treatment. In the brain injury world, per say, I can relate to the stance of wanting to distance ourselves from what the word “concussion” is becoming and try to separate its components, such as headaches, and give it another name as it clearly happens in the cited article. For example in this study the author seem to attempt to separate the diagnosis between what a concussion is and what traumatic related headaches or migraines are. Headaches and migraines most times are components of a concussion were its nature, historic and genetic component challenges current diagnosis and treatment methods.
Have you dealt with headaches and/or migraines pre and post injury? Can you separate them and what approaches have you tried with or without success?
Posted 11 November 2013 by prehab
There are many instances in which athletes present with chronic headaches post concussion. Some of them with history of migraines trigger an aggressive approach from some pediatricians. Family history of migraines, for example, increases the possibility of developing migraines and that may trigger a closer look at the benefits of headache medication. In most instants analgesics are indicated but in some times overuse of pain medication may cause the syndrome to worsen. Dr. Geoffrey Heyer, MD reports in his study presented as an abstract, here referenced, headache medications may worsen headaches after concussions and may cause chronification of a headache syndrome.
Have you had any experience in this regard? Anecdotes? How did it resolve?
Posted 10 March 2013 by prehab
The processes in which a brain deals with a concussion are many and therefore a variety of treatments are being formulated by many scientists currently involved in research. The latest research points to the immune system and is something to be concerned about, according to a new study published in the Journal Plos One, last week.
As reported by Popular Science, Sub-concussive jostling to the brain could lead to a series of events that ends with cells in the immune system attacking the brain, says Jeffrey Bazarian, a physician at the University of Rochester Medical Center and a co-author on a new study about brain injury as an autoimmune response.
Here is Bazarian and his colleagues’ idea. After a head hit, even if it doesn’t result in a concussion, the blood-brain barrier that separates the brain from the rest of the circulatory system opens up, releasing a brain protein called S100B into the blood. High levels of S100B in the blood are already known as marker for head injury; in Europe, emergency rooms give head injury patients S100B tests to decide whether they need a CAT scan.
We may be onto something here if further research efforts can shed additional light on this issue that may result in a possible pill or vaccine to block the Immune response. Furthermore, testing for S100B may be an ingenious idea for the pediatric population, if safe. It can be a useful measure to prevent unnecessary CAT scans known be harmful to the developing brain.
Posted 6 March 2013 by prehab
Great advances in technology makes diagnosing concussions possible. High definition fiber tracking is a promising technology to directly measure breaks in brain fibers that control function. This technology will allow for biological diagnosis of brain injury.
Posted 18 February 2013 by prehab
Younger children are more resilient! Or are they? As I read more and experience different recovery rates in youth, the notion that children are more resilient, or that they heal faster, may apply more to anatomical injuries of an orthopedic background. I see my own children healing in record time and young clients with sport related injuries that barely need rehabilitation post injury. But when it comes to brain injury, it appears as if it was the opposite. Keith Yeates, a neuropsychologist at Nationwide Children’s Hospital and professor of pediatrics at the Ohio State University, says there are many reasons why children may be more susceptible to long-term effects after TBI or concussion.
“The pathophysiology of the injury tends to be a little bit different in kids because there are differences in the composition of the brain and there are differences in the size of children’s heads relative to the size of their body,” he says. “Their necks are less strong so they are subjected to different deceleration forces. And from a psychological perspective, young kids still have a lot to learn. They don’t have the stored knowledge and acquired skills like adults to fall back on.”
As emergency medicine evolves in the area of traumatic brain injury there is an opportunity to change the pathophysiology that takes place post injury. After head injury there is a storm of neurotransmitters that overwhelms, stresses, and challenges the developing brain. If it can be attenuated, all involved providers as a team, may see a better future of concussion treatment. In the meantime even with the limitations in imaging and evaluative methods, we may be looking at a possible “scaring” effect that may explain the traceable behavior changes and deficits that tend to reappear later on in some of our young patients. Let’s not rely on their resiliency when there are so many unknowns.
“Children who sustained a severe TBI at a younger age are more likely to have a range of deficits that include deficits in their thinking skills, deficits in their academic skills, and also social problems,” says Yeates in a recent study published in Rehabilitation Psychology. “They tend to have trouble making or keeping friends. And they’re at greater risk for certain types of emotional and behavioral problems.”
Mayer and colleagues examined the brains of 15 children who had recently experienced a concussion using DTI. They administered cognitive testing four months later and repeated the scanning. They found that structural changes in the children’s white matter remained months after the injury—even after cognitive and other symptoms had disappeared.
I continue in the quest for better understanding about the subtle changes these young athletes present after concussions. As I hope that imaging evolves at a faster pace, I realize how much more conservative I need to get. Designing and formulating rehabilitation strategies mostly concentrated on limitation of stressing mechanisms needs to be customized.
What is the biggest challenge to concussion management? Improving awareness about what the new evidence is showing to parents and members of the potential management team. They only realize they are part of the team when a youngster gets hurt but if information flows well before an injury, we may be looking at better odds. Pediatricians, neurologists, physical therapists, trainers, coaches, parents and their own teammates are that team. Let me underscore the value of their teammates. Their peer pressure can cause the athlete to prematurely return to sport or avoid reporting the injury altogether.
There is plenty of research funding now by the NFL, NCAA and other organizations to improve the efficacy of the rehabilitation process but until then rehabilitation professionals should lead the way before young athletes are further exposed to catastrophic injury. As a parent, I’m not taking any risks and that is how I see every case, and so should every one in their care. Click here to access the Dr. Yeates’ study published in Rehabilitation Psychology 2012
Posted 15 February 2013 by prehab
I have a problem calling concussions “minor”. There is nothing minor about a brain injury that can cost children their dreams, normal mental and or physical function, or in some cases can cost them their lives. Even though there is a ton of information now available about concussions, which I’m glad to finally see, I still have some serious concerns. There are few cases of what I call hyper-awareness and it can lead to chaos. Hyper-awareness and ignorance is causing some concussed young athletes unintended neglect as they pass from one expert to another. Instead of treating a concussion like a “hot potato” condition (“it’s not mine”), professionals who receive concussed athletes should treat it delicately and focus on allowing the patient to heal properly.
Fortunately, pediatricians are starting to catch up and get assistance with formulating customized resting for concussed patients. They do this by relying on neurocognitive and vestibular assessment, baseline assessment and educated parents and teachers. Then the pediatricians can take better charge.
Rest is well understood now to allow a concussed brain its return to normal state of homeostasis. Rest attenuates the typical storm of neurotransmitters that overwhelms and inhibits the brain during a concussion. Treatment however does not happen at the doctors office and very rarely it requires medication. What allows the developing brain to heal is strict following of the customized resting formulated at the school and at home as I presented to Dr. Nguyen, Smoak, and Jennifer Baxley at Charlotte Pediatric Clinic-Steele Creek located in Charlotte, NC.
Provided that major or more catastrophic injury was cleared, immediately after the injury, and prevention from exposure to another injury while healing, concussion treatment and management should stay at the watchful eye of the pediatrician who, to begin with, knows their young patients best.