Brain injuries in youth may leave a long lasting trace

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

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Pediatricians may be most appropriate for managing concussions

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.

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Concussions: The neurosurgeon’s role and the current scientific evidence and management strategies.

Posted 10 February 2013 by prehab

Neurosurgeons often manage patients with extracranial injuries that have concomitant concussions. In these cases, neurosurgeons are often the only “concussion experts” that patients encounter.

In recent decades, concussions have received unprecedented attention from the scientific community. The definition of the term has become more refined, and epidemiological data have revealed how remarkably common the injury is.

A neurosurgeon’s intimate knowledge of various head injuries from similar mechanisms gives a distinct advantage in the ability to educate athletes about the possible consequences of their injury. In the past, involvement in concussion management has been less than that of trainers, sports medicine physicians, rehabilitation specialists or other primary care providers. This is mostly attributable to the limited supply of neurosurgeons and the mostly non-surgical pathology of concussions.

Neurosurgeons are limited in number but critical in their knowledge when complication arises. They can provide a solid foundation for those that do provide “frontline” care and be willing to provide assistance and insight whenever consulted. A few neurosurgeons however, have already taken the initiative and are getting more and more involved such as Dr. Tanvir Choudhri, MD or some one like Dr.Robert Cantu, MD who already leads on the frontline role of dealing with concussions. Read more about the role of Neurosurgeons in this, in-depth, study published by Surgical Neurology International.

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Sports Concussions Detectable by Changes in Cerebral Blood flow.

Posted 9 February 2013 by prehab

Pediatric SRC (sports related concussions) is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury.

In a recent study investigating changes in intracranial blood concluded that blood flow decreased post injury and improvements toward control values occurred in only 27% of the participants at 14 days and 64% at .30 days after SRC. The significance of this finding may help healthcare providers closer to finding more accurate testing methods for concussions, quantifiable information to detect severity, speed of recovery and safety. Something Harvard may want to get the hands into with the recent 100Mil NFL donation for their research purposes. See full Study. GE is also working on devices that may assist on improving imaging that may be sensitive to concussions.

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Va. House panel rejects youth sports concussions bill

Posted 28 January 2013 by prehab

Under the proposal, Del. Rich Anderson, R-Prince William County, coaches and employees would have had to complete annual training on concussions. School divisions and youth sports organizations also would have had to provide concussion information to parents and develop procedures for recognizing concussion symptoms and ensuring athletes who suffer those head injuries receiving medical clearance before returning to the field. HB1719

In the current law, passed in 2010 requires the Board of Education to develop guidelines for “concussion education, awareness, and management” for public school athletes and expanded the code to include sports groups that use public property.

Read the proposal

 

 

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“Asymptomatic”; Subjective but key to safety post concussion.

Posted 20 January 2013 by prehab

“Asymptomatic; is a state that concussed athletes need to demonstrate before they are accepted back to competitive play,” According to Dr. Alex Gometz, DPT, CIC, who discussed the issue of asymptomatic concussion with concerned pediatricians at Park Avenue Pediatrics in NYC, last week. In order to prevent exposure to catastrophic injury, there should be a clear medical team agreement on the athlete’s safety before he is exposed to the possibility of another injury. There have been hundreds of examples of “concussions gone wrong”, on TV ads and YouTube videos in the past few years that have hit to close to home.

As echoed in a recent statement by the American Medical Society for Sports Medicine (AMSSM), an athlete with a concussion should not return to practice or competitive play until all symptoms have resolved. The statement was published in the January issue of the Clinical Journal of Sport Medicine and headed by Dr. Kimberly Harmon, MD. The report provides an evidence-based, best practices summary to assist physicians with the evaluation and management of sports concussion.

To ensure safety, Dr. Gometz advises that the developing brain has to return to a pre-injury state of homeostasis demonstrated at rest during a thorough review with their pediatrician. Secondly, athletes should follow a carefully tailored exertion-infused rehabilitation program by Concussion Management of New York. There is a proven period of increased vulnerability post-injury. No game is worth risking the catastrophic consequences of repeated trauma in a poor state of metabolic ability to sustain injury.

The state of concussions in the country has now alarmed the established sports dominant institutions but prompted the government to investigate methods of standardization of assessment and treatment. Recently, the Institute of Medicine (IOM) has formed a committee to study sports-related concussions in youth from elementary school through young adulthood. The committee held its first meeting on January 7.

According to the IOM Web site, the committee will review the available literature on delayed concussion symptoms and concussions, in the context of developmental neurobiology, in terms of their causes, relationships to hits to the head or body during sports, and the effectiveness of protective devices and equipment. You can read the full statement by the AMSSM here.

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Correlation between nonuse of bicycle helmets and risk of fatal head injury

Posted 17 January 2013 by prehab

Not wearing a helmet while cycling is associated with an increased risk of sustaining a fatal head injury. Policy changes and educational programs that increase the use of helmets while cycling may prevent deaths.

Policies and campaigns that promote helmet use may decrease cycling mortality, which contributes substantially to mortality among young adults worldwide. Concomitant educational programs and public awareness campaigns may account for some of the positive effects of enacting helmet legislation. Cyclists less than 18 years of age are required by law to wear a helmet in Ontario. That 88% of decedents in our study were older than 18 years (and 18% were > 60 yr) suggests a gap in public policy. Full study report published in CAMJ

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Poor Reliability of Concussion History in Athletes

Posted 15 January 2013 by prehab

Recent research has explored the long-term neurodegenerative effects associated with recurrent concussion in athletes. Findings from a number of former professional football players found that the number of concussions sustained during their professional careers was associated with the rate of diagnosed clinical depression and late-life cognitive impairment. A limitation of these studies was the use of a self-reported history of concussion.

Imperfect recall can generate bias in studies when the proportion of events recalled is associated with the health end points of interest (such as neurodementia or depression). Associations observed in these studies may be inaccurate if athletes differ in their knowledge and recognition of concussion symptomatology in a manner that is associated with the health outcome of interest. Taking depression as an example, if depressed athletes tend to overreport their concussions (or if nondepressed athletes tend to underreport their concussions), then the association between concussion and depression observed in these studies might be due to bias. Without data about the reliability of concussion self-report, there will always be a concern that the observed association between concussion and neurodementia/depression could be due to differential recall bias. Here is a copy of the abstract published in Med Sci Sports Exercise in 2012

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Concussed athletes may require extended recuperation time before full recovery, study finds.

Posted 12 January 2013 by prehab

Young athletes may need a longer period of time to recover well after a concussion than previously believed, according to a study recently published in Medicine & Science in Sports & Exercise. Researches from the University of Oregon Department of Human Physiology examined the attention and executive function of 20 athletes measured against  a 20 person control group. Among their findings, concussed participants showed significant impairment on executive function 2 months after injury. The conclusions suggest that athletes should be evaluated for executive function post injury before returned to sports. Dr. Alex Gometz, DPT at Concussion management of NY suggests constant supervision and constant periodical neurocognitive testing before returning to sports and an exertion program. New data available suggests athletes are returning to sports before they are completely safe and should be allowed extended periods of rest for proper healing.  Read complete study details. 

Posted in Concussions in children,Uncategorized | Leave a reply

Escalating trend in sports concussions

Posted 8 January 2013 by prehab

Escalating trend in documented concussions due to improvements in the detection and clinical management of concussion says the NCAA. Concussion rates in football had been escalating over a 21-year period beginning in the early 1980s. But the trend stabilized in recent years, becoming relatively flat from 2004-12. NCAA Director of Health and Safety David Klossner said the reasons for the previous escalating trend are not well documented but could be due to multiple factors, including improvements in the detection and clinical management of concussion. Read the full article.

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