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.
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
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.
The North Park Hockey League feels it is vital to do what is best for the athletes and at this time is recommending concussion baseline testing before each season. With the recent focus on the negative effects of concussions on the long-term health of athletes, especially of those athletes in the most physical contact sports like hockey, they felt if was time to team up with a company that delivers the most reliable test procedure. The North Park Hockey League is one step up relying on brain injury experts with no ties to one test but what is best for each individual from baseline testing, clinical assessments and management at Concussion Management of New York.
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