Brain injuries in youth may leave a long lasting trace

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

Pediatricians may be most appropriate for managing concussions

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.