What determines recovery time for a child after a traumatic brain injury?

This article explains why it takes children different amounts of time to recover from traumatic brain injury.

Why do some youngsters bounce back quickly from a traumatic brain injury, while others suffer devastating side effects for years?

New UCLA/USC research suggests that damage to the fatty sheaths around the brain's nerve fibers--not injury severity-- may explain the difference. Published in the July 15 edition of the Journal of Neuroscience, the finding identifies possible biomarkers that physicians could use to predict higher-risk patients who require closer monitoring.

The study is the first to combine imaging scans with recording of the brain's electrical activity to reveal how damage to the protective coating around the brain's circuitry affects how quickly children and teens can process and recall information after a concussion or other head trauma.

"Just as electricians insulate electrical wires to shield their connections, the brain's nerve fibers are encased in a fatty tissue called myelin that protects signals as they travel across the brain," explained Dr. Christopher Giza, director of the UCLA Steve Tisch BrainSPORT Program and a professor of pediatrics and neurosurgery at UCLA's David Geffen School of Medicine and Mattel Children's Hospital. "We suspected that trauma was damaging the myelin and slowing the brain's ability to transmit information, interfering with patients' capacity to learn."

To test their hypothesis, the scientists assigned a series of mental tasks to 32 youngsters ages 8 to 19. Each had suffered a moderate to severe brain injury in the past five months. The tests evaluated the children's processing speed, short-term memory, verbal learning and cognitive flexibility.

The UCLA team recorded the kids' brains' electrical activity to test how quickly their nerve fibers could transmit information, and then imaged the wiring to assess its structural soundness.

When the scientists compared the patients' results to those of a matched control group of 31 healthy children, they discovered dramatic differences.

Half of the brain-injury group showed widespread damage to the myelin insulating their brain's circuitry. These patients performed 14 percent more poorly on the cognitive tests and their wiring worked three times slower than healthy children's.

Scans of the other 16 patients in the brain-injury group showed their myelin was nearly intact; and their brains were able to process information as quickly as healthy children's. They performed 9 percent better on the cognitive tasks than the youngsters with more myelin damage, though not as well as the uninjured kids.

"Our research suggests that imaging the brain's wiring to evaluate both its structure and function could help predict a patient's prognosis after a traumatic brain injury," said first author Emily Dennis, a postdoctoral researcher at USC's Keck School of Medicine.

"Our next step will be to explore how brain biomarkers change during a patient's first year of recovery when most people recapture some cognitive function," said principal investigator Robert Asarnow, a professor of psychiatry and psychology at UCLA's Semel Institute for Neuroscience and Human Behavior and College of Letters and Science.

Traumatic brain injury is the single most common cause of death and disability in children and teens, according to the U.S. Centers for Disease Control.

The research was supported by funding from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Biomedical Imaging and Bioengineering, and the National Cancer Institute.

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Study shows younger children recover quicker from concussions than adolescents

A study shows that younger children recover quicker from concussions than adolescents do.

Children aged 10 years and younger appear to recover faster from concussion than those older than 10, study findings indicate.

The difference may be related to symptom severity, mechanism of injury, or a lower incidence of premorbid conditions, according to Rejean M. Guerriero, DO, of Boston Children's Hospital and Harvard Medical School, who reported the findings during a session at the American Academy of Neurology 2015 Annual Meeting.

It's well understood that young adults have slower neurocognitive recovery compared to adults, however there's little data on children in the 5- to 10-year range. Using a Standardized Clinical Assessment and Management Plan, Guerriero and colleagues collected data on 466 patients who presented at a pediatric neurology clinic with concussion, including 93 patients 10 years or younger and 373 patients aged 10 to 21. Data included demographics, clinical presentation, premorbid conditions, diagnostic testing, and treatments.

Overall, premorbid conditions were more common among older patients than younger patients, especially headache (14.37 versus 12.77 years, P<0.001) and psychiatric comorbidities (22.9% anxiety, 8.9% depression, 15.6% attention problems vs. 9.8%, 0%, 7.3%, respectively), while learning disabilities and ADHD/ADD were equally as common among both older and younger populations, particularly in a pediatric neurology practice.

Children 10 years and under had significantly lower scores on the post-concussion symptom scale across all domains — headache, vestibular, cognitive, and sleep — than older children, except for emotional symptoms. Younger children also recovered more quickly from concussion (mean 61 days for ≤10 vs. 74 days for >10, P=0.01). Guerriero noted that while the data from the study can be applied to all children, the younger children in this unique population (neurology practice vs. primary care/clinic/ED) took longer than typical to recover from concussion: 14 – 30 days for standard recovery vs. 60 days in the study.

“It's hard to know whether (comorbidities) affect susceptibility,” Guerriero said, referencing the younger population's seeming ability to recover from concussion faster. “It's certainly well known that learning disabilities, migraine headaches, and behavioral issues are all risk factors for prolonged neurocognitive symptoms, but at this point it seems less likely that those characteristics put patients at greater risk for concussion.”

The researchers also suggested that the similar emotional symptom scores in both younger and older children may reflect the post-concussion symptom scale's inability to detect subtle emotional symptoms in younger children.

“Younger kids may be more resilient or they may not know better, so they  bounce back (from injury) and think, ‘What do I have to be anxious about? It's fine and I feel better,'  where as older kids, who may watch the news or have other exposures, think ‘Jeez, am I going to have chronic brain problems now?'”

While children 10 and under may be more resilient in terms of knowledge of injury and brain health baseline, Guerriero stressed that physicians need to be more conscious of subtle changes in behavior that may not be self-reported by younger children or their parents.

“There are other scales specifically geared toward identifying emotional issues in younger children that highlight trouble with transitions and irritability, which physicians can use in younger patients that may be more sensitive than aspects of the post-concussive symptom score.”

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A parent's thoughts on concussions can hinder treatment and recovery

A study shows that a parent's misconceptions about concussions and treatment hinders treatment and recovery.

With football season in full swing, there's no shortage of talk about young players -- from high school down to the pee wee levels -- suffering from concussions. Yet many parents may lack knowledge about this mild traumatic brain injury, according to two studies to be presented Oct. 10 at a pre-conference symposium on pediatric sports medicine at the American Academy of Pediatrics (AAP) National Conference & Exhibition in San Diego.

Nearly 175,000 children are treated in U.S. emergency rooms each year for concussions due to sports-related activities, according to the Centers for Disease Control and Prevention. Parental knowledge of the signs and symptoms of concussion and recognizing that this is a brain injury is important to ensure children are diagnosed in a timely manner and get appropriate treatment.

Two separate studies looked at parents' knowledge of concussion and common misconceptions. They will be presented as part of the Peds21 symposium, "1, 2, 3, Go! Sports in the World of Pediatrics -- Playing it Safe and Making it Fun!" in the San Diego Convention Center.

For the first abstract, titled "Parental Knowledge of Concussion," 511 parents of children ages 5-18 years who sought care at a pediatric emergency department within two weeks of their child suffering a head injury filled out a 24-item survey. They were asked questions about their demographics, their child's head injury, and general questions related to their knowledge of concussion and its treatment.

Results showed about half of parents correctly identified a concussion as a brain injury that could lead to symptoms such as headache or difficulty concentrating. No parental demographics (age, sex, education or prior history of sports participation) significantly predicted parents' knowledge about concussions.

The survey also indicated that almost all parents (92 percent) were aware that they should stop their child from playing and see a physician if they suspected a concussion. Yet only 26 percent were aware of guidelines on when their child could return to sports and school work.

"Our study showed that the vast majority of parents knew what to do if they suspected a concussion in their child and in most cases understood the clinical importance of this injury as a brain injury," said lead author Kirstin D. Weerdenburg, MD, FAAP, pediatric emergency medicine fellow at Hospital for Sick Children, Toronto, Ontario, Canada.

"The study also highlights that a physician visit shortly after the injury is important to confirm the diagnosis for parents and to inform parents of return to play/learn guidelines to ensure a proper recovery and prevent a second concussion while the brain is still healing," Dr. Weerdenburg said.

The authors of the second abstract, "Parental Misconceptions Regarding Sports-Related Concussion," also surveyed parents to assess their knowledge of concussions. The online survey was completed by two groups -- 214 parents whose children were evaluated at a sports medicine clinic for musculoskeletal or mild traumatic brain injuries (group 1) and 250 parents of students at a local private school (group 2).

The survey included questions that gauged their knowledge of and attitudes about concussions as well as demographic information.

The majority of parents in both groups did well overall but had several misconceptions:

• About 70 percent in group 1 and 49 percent in group 2 incorrectly believed that brain imaging (CT/MRI scans) can be used to diagnose concussion.
• About 55 percent in group 1 and 52 percent in group 2 did not know that "bell ringer or ding" is synonymous with concussion.
• Reduced breathing rate was incorrectly identified as a symptom by 25 percent and 29 percent, respectively.
• Difficulty speaking was incorrectly identified as a symptom by 75 percent and 79 percent, respectively.

"Our study highlights the fact that many parents are still in need of education regarding concussion identification and post-injury evaluation. Even those highly educated parents were prone to misconceptions," said senior author Tracy Zaslow, MD, FAAP, medical director of the sports medicine and concussion program at Children's Orthopaedic Center, Children's Hospital Los Angeles. "False perceptions such as the ones pinpointed by our study may impact when medical care is sought after concussion and lead to less than optimal home care."

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Athletes worsen after recovering from concussion and returning to exercise

A study showed that athletes who have recovered from a concussion can worsen after returning to exercise.

Athletes who seem to have recovered from a concussion may actually show a subtle worsening in a particular mental ability after they return to exercise, a small study suggests.

The findings come from a study of 19 high school athletes who suffered a concussion and then got medical clearance to return to physical activity -- most often football, although a few were on soccer, wrestling or volleyball teams.

Researchers found that for 12 of those athletes, a particular mental ability that had been improving post-concussion reversed course once they were up and moving again.

Specifically, the athletes' ability to simultaneously walk and do simple mental tasks "regressed," the researchers report in the journal Medicine & Science in Sports & Exercise.

In real-life terms, that means walking down the street while talking to a friend would be a bit harder, explained Li-Shan Chou, one of the researchers on the study.

The shift would be too subtle for a person to actually notice, said Chou, a professor of human physiology at the University of Oregon in Eugene.

But he and his colleagues were able to detect the regression in lab tests where the athletes walked while performing basic mental tasks -- like listening to a spoken word, then saying whether it was a high or low pitch.

What does it all mean? That's not clear, said Kenneth Podell, a concussion expert who was not involved in the study.

For one, since the study group was so small, the findings need to be replicated in larger studies to know whether they are "real," according to Podell, co-director of the Houston Methodist Concussion Center in Texas.

He also questioned how the athletes could show an improvement in their test performance early on, when they were "most concussed," but then worsen after all their other signs and symptoms had improved.

Chou agreed that the implications of his findings are unclear. For now, he said the study highlights the importance of giving concussions time to heal.

"Have patience, and give the brain time to recover," Chou added.

According to the American Academy of Neurology (AAN), more than 1 million athletes in the United States suffer a concussion each year.

Concussion symptoms include headache, dizziness, nausea, ringing in the ears, fatigue and confusion -- though these problems may not become noticeable until hours after the jolt to the head. And contrary to popular belief, concussions usually do not cause unconsciousness.

When athletes are recovering from a concussion, the "standard of care" is to gradually return them to physical activity before they can get back on the field, Podell said.

In fact, all 50 states and the District of Columbia now have some kind of law on youth concussions, protecting athletes from returning to the playing fields too soon.

But there is no "set timeline" for safe return to play, according to the AAN. And judging recovery is subjective, Chou said, because it involves asking patients how they feel.

The current findings are based on 19 high school athletes who were periodically assessed for two months after sustaining a concussion. All returned to physical activity, with medical clearance, during that time.

Chou's team found that once they were active again, 12 of the athletes showed some reversal in their ability to walk and perform mental tasks simultaneously. The problem showed up as a subtle change in their walking speed or balance.

Still, Podell said, it's not clear what to make of that. Even if the athletes' gait did regress when they first started physical activity, it might have been "fine" by the time they got back into their sport, he noted.

"The take-away for parents is, the return from concussion is complex, and the best clinical practice calls for a slow and gradual return to activity under the guidance of professionals," Podell said.

But it's not only physical activity that matters, he added. Concussed kids should also take a break from mental stress and only gradually return to schoolwork.

"Just because a student-athlete is ready to exercise does not mean they are 100-percent ready for a full load at school," Podell said.

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Study: Concussions take longer to heal from than previously believed

A study analysed people's cerebrospinal fluid to show that it takes longer to heal from concussions than previously believed.

Scientists at the Sahlgrenska Academy, University of Gothenburg, have shown that analysis of the cerebrospinal fluid after concussion can be used to determine the magnitude of brain injury and to follow its course. The studies show that recovery from concussion takes much longer time than previously known, and this may be of major significance for athletes of all ages in return to play considerations.

Sanna Neselius is a scientist at the Sahlgrenska Academy and member of the medical commission of the Swedish Boxing Federation. Her previous studies have shown that amateur boxing causes damage to nerve cells, that can take more than two weeks to heal. This discovery led to her being offered a place in the International Olympic Committee's expert group for boxing-related head injuries.

Sanna Neselius has now defended her doctoral thesis at the Sahlgrenska Academy, in which she shows that sports-related concussion heals much slower than previously known.

Four months recovery

"It has previously been believed that concussion heals in 7-10 days, and the Swedish Boxing Federation has decided the rest period to be of one month after a concussion, in order to be on the safe side. But our studies show that a concussion, such as may be experienced after being knocked out, can take more than four months to heal," says Sanna Neselius, who is herself a former boxer.

Further, the results show that repetitive head trauma in boxing, damages nerve cells in the brain, even though the boxer may not show any concussion symptoms.

Prevent resuming too early

Concussion is one of the most common sports-related injuries, and more athletes experience it every year. In recent years, focus has been directed on the effects of repeated concussions, in which athletes in such sports as ice hockey may be affected by long-term effects.

The cerebrospinal fluid samples analysed by Sanna Neselius and her colleagues can be followed until normalization and thereby be a valuable tool to prevent athletes resuming sport too early.

"The assessment today is often based on physical symptoms, neuropsychological tests, and the neurological examination of the athlete. Our studies show that these tests are not sensitive enough, nor can we rely on the athletes self-reported lack of symptoms. Concussion symptoms usually pass after a few days, but the neurological damage may still be present," says Sanna Neselius.

Safe rehabilitation

She continues: "The first sample is recommended to be taken 10-14 days after the concussion. This allows us to see the magnitude of the injury, and gives an idea of how long the healing process will be. I hope that brain injury markers in the cerebrospinal fluid, and hopefully also later in blood, can be used at all levels in all sports. By this we can use individual measurements to plan and guarantee safe rehabilitation."

Sanna Neselius points out that the brains of children and adolescents are more sensitive and require longer time to heal.

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Girls suffer worse concussions than boys do

A study looked into how gender affects concussion and showed that girls suffer worse concussions than boys do.

Girls who suffer a concussion may have more severe symptoms that last longer compared to boys, according to new research that builds on other studies finding gender differences.

"There have been several studies suggesting there are differences between boys and girls as far as [concussion] symptom reporting and the duration of symptoms," said Dr. Shayne Fehr, a pediatric sports medicine specialist at Children's Hospital of Wisconsin.

In his new study, Fehr also found those differences. He tracked 549 patients, including 235 girls, who sought treatment at a pediatric concussion clinic.

Compared to the boys, the girls reported more severe symptoms and took nearly 22 more days to recover, said Fehr, also an assistant professor of pediatric orthopedics at the Medical College of Wisconsin.

He was due to present the findings this week at the annual meeting of the American Medical Society for Sports Medicine, held in New Orleans. Studies presented at medical meetings are typically viewed as preliminary until published in a peer-reviewed journal.

A concussion is any brain injury that disturbs normal functioning. Concussions are typically caused by a jolt or blow to the head, often in collision sports such as hockey or football, according to the American Academy of Pediatrics (AAP).

In recent years, experts have advised coaches, players and parents that athletes should not return to play until they are seen by a doctor if a concussion is suspected.

In the new study, Fehr tracked patients aged 10 to 18, all treated between early 2010 and mid-2012. Each patient reported on their symptoms, how severe they were and how long it took from the time of the injury until they were symptom-free.

In addition to reporting more severe symptoms, girls took an average of 56 days to be symptom-free. In comparison, the boys took 34 days. Overall, the time to recovery was 44 days when boys and girls were pooled.

That duration of symptoms, Fehr said, is much longer than what people commonly think. "Commonly you hear that seven to 10 days [for recovery] is average," he said.

Fehr did not find age to be linked with severity of symptoms. Most of the injuries -- 76 percent -- were sports-related, with football accounting for 22 percent of the concussions.

The top five reported symptoms were headache, trouble concentrating, sensitivity to light, sensitivity to sound and dizziness. Boys and girls, in general, reported the same types of symptoms, Fehr said, but the girls reported more severity and for a longer time period.

"This confirms what has been reported before," said Dr. John Kuluz, director of traumatic brain injury and neurorehabilitation at Miami Children's Hospital, who reviewed the findings.

While he said the 44-day recovery seems lengthy, he added that it probably reflects the boys and girls studied. They all went to a concussion clinic, so their injuries may have been more severe.

What's not known, Fehr said, is why the differences exist and whether they are related to more reporting of symptoms right after the injury by girls or if girls are truly more significantly affected.

"I wouldn't treat girls any differently than boys,'' he said.

For both genders, it's important to be seen by a doctor and not return to play prematurely, which can be dangerous or even fatal, according to the AAP. Anyone with a history of concussion is at higher risk for another injury.

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Concussion recovery could be influenced by menstrual cycle

Study shows that recovery after a concussion may be influenced by when in a woman's menstrual cycle the concussion occurred.

Researchers found that women injured during the two weeks leading up to their period (the premenstrual phase) had a slower recovery and poorer health one month after injury compared to women injured during the two weeks directly after their period or women taking birth control pills.

The University of Rochester study was published today in the Journal of Head Trauma Rehabilitation. If confirmed in subsequent research, the findings could alter the treatment and prognosis of women who suffer head injuries from sports, falls, car accidents or combat.

Several recent studies have confirmed what women and their physicians anecdotally have known for years: Women experience greater cognitive decline, poorer reaction times, more headaches, extended periods of depression, longer hospital stays and delayed return-to-work compared to men following head injury. Such results are particularly pronounced in women of childbearing age; girls who have not started their period and post-menopausal women have outcomes similar to men.

Few studies have explored why such differences occur, but senior author Jeffrey J. Bazarian, M.D., M.P.H. says it stands to reason that sex hormones such as estrogen and progesterone, which are highest in women of childbearing age, may play a role.

"I don't think doctors consider menstrual history when evaluating a patient after a concussion, but maybe we should," noted Bazarian, associate professor of Emergency Medicine at the University of Rochester School of Medicine and Dentistry who treats patients and conducts research on traumatic brain injury and long-term outcomes among athletes. "By taking into account the stage of their cycle at the time of injury we could better identify patients who might need more aggressive monitoring or treatment. It would also allow us to counsel women that they're more -- or less -- likely to feel poorly because of their menstrual phase."

Although media coverage tends to focus on concussions in male professional athletes, studies suggest that women have a higher incidence of head injuries than men playing sports with similar rules, such as ice hockey, soccer and basketball. Bazarian estimates that 70 percent of the patients he treats in the URMC Sport Concussion Clinic are young women. He believes the number is so high because they often need more follow-up care. In his experience, soccer is the most common sport leading to head injuries in women, but lacrosse, field hockey, cheerleading, volleyball and basketball can lead to injuries as well.

Sex hormone levels often change after a head injury, as women who have suffered a concussion and subsequently missed one or more periods can attest. According to Kathleen M. Hoeger, M.D., M.P.H., study co-author and professor of Obstetrics and Gynecology at the University of Rochester School of Medicine and Dentistry, any stressful event, like a hit to the head, can shut down the pituitary gland in the brain, which is the body's hormone generator. If the pituitary doesn't work, the level of estrogen and progesterone would drop quickly.

According to Bazarian, progesterone is known to have a calming effect on the brain and on mood. Knowing this, his team came up with the "withdrawal hypothesis": If a woman suffers a concussion in the premenstrual phase when progesterone levels are naturally high, an abrupt drop in progesterone after injury produces a kind of withdrawal which either contributes to or worsens post concussive symptoms like headache, nausea, dizziness and trouble concentrating. This may be why women recover differently than men, who have low pre-injury levels of the hormone.

Hoeger and Bazarian tested their theory by recruiting144 women ages 18 to 60 who arrived within four hours of a head hit at five emergency departments in upstate New York and one in Pennsylvania. Participants gave blood within six hours of injury and progesterone level determined the menstrual cycle phase at the time of injury. Based on the results, participants fell into three groups: 37 in the premenstrual/high progesterone group; 72 in the low progesterone group (progesterone is low in the two weeks directly after a period); and 35 in the birth control group based on self-reported use.

One month later, women in the premenstrual/high progesterone group were twice as likely to score in a worse percentile on standardized tests that measure concussion recovery and quality of life -- as defined by mobility, self-care, usual activity, pain and emotional health -- compared to women in the low progesterone group. Women in the premenstrual/high progesterone group also scored the lowest (average 65) on a health rating scale that went from 0, being the worst health imaginable, to 100, being the best. Women in the birth control group had the highest scores (average 77).

"If you get hit when progesterone is high and you experience a steep drop in the hormone, this is what makes you feel lousy and causes symptoms to linger," said Bazarian. "But, if you are injured when progesterone is already low, a hit to the head can't lower it any further, so there is less change in the way you feel."

The team suspected that women taking birth control pills, which contain synthetic hormones that mimic the action of progesterone, would have similar outcomes to women injured in the low progesterone phase of their cycle. As expected, there was no clear difference between these groups, as women taking birth control pills have a constant stream of sex hormones and don't experience a drop following a head hit, so long as they continue to take the pill.

"Women who are very athletic get several benefits from the pill; it protects their bones and keeps their periods predictable," noted Hoeger. "If larger studies confirm our data, this could be one more way in which the pill is helpful in athletic women, especially women who participate in sports like soccer that present lots of opportunities for head injuries."

In addition to determining menstrual cycle phase at the time of injury, Bazarian plans to scrutinize a woman's cycles after injury to make sure they are not disrupted. If they are, the woman should make an appointment with her gynecologist to discuss the change.

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Concussion recovery requires the brain to compensate

A study claims that increased brain activity a few weeks after a concussion shows that the brain compensated to help recover.

Concussion patients have irregular brain activity within the first 24 hours after their injury but increased levels of brain activity a few weeks later, which suggests that the brain may compensate for the injury during recovery, a new study reports.

Researchers used functional MRI to study the recovery of 12 high school football players with concussion and compared them to 12 uninjured teammates. The concussed players underwent brain scans at 13 hours and again seven weeks after their head injury, and the uninjured players had brain scans at the same time.

At 13 hours, the concussed athletes had typical symptoms such as decreased reaction time and reduced mental abilities. Their brain scans revealed decreased activity in certain areas of the right hemisphere of the brain. This suggests that their reduced mental abilities may be related to underactivation of attentional brain circuits, according to the researchers.

At seven weeks, the concussed players showed improvement in their mental abilities and normal reaction time. Brain scans at that time revealed that the concussed athletes had more activation in the brain's attentional circuits than the uninjured players.

"This hyperactivation may represent a compensatory brain response that mediates recovery," study lead author Thomas Hammeke, a professor of psychiatry and behavioral medicine at the Medical College of Wisconsin, said in a college news release. "This is the first study to demonstrate that reversal in activation patterns, and that reversal matches the progression of symptoms from the time of the injury through clinical recovery."

The study appears in the September issue of the Journal of the International Neuropsychological Society.

"Deciding when a concussed player should return to the playing field is currently an inexact science," study senior author Dr. Stephen Rao, director of the Schey Center for Cognitive Neuroimaging at the Cleveland Clinic, said in the news release. "Measuring changes in brain activity during the acute recovery period can provide a scientific basis for making this critical decision."

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What parents should know about concussions

This article reviews the signs and symptoms of concussions that parents of athletes should be aware of. - JR

Parents of young athletes know that along with the many benefits of participating in sports, there comes a certain amount of injury risk. And while most would agree that the benefits of being active and involved in athletics outweigh those risks, it’s important to make sure your child gets proper treatment if an injury occurs. As more evidence surfaces about long-term health challenges related to concussions, it’s especially crucial that parents bring themselves up to speed on the proper procedures for caring for an athlete who experiences a concussion.

The most important thing parents need to know about concussions is that if an athlete exhibits any signs or experiences any symptoms of a concussion, he or she should be immediately removed from play. While this recommendation is nothing new, the American Academy of Neurology (AAN) is again emphasizing its importance with the release of its updated 2013 sports concussion evidence-based guidelines.

“Among the most important recommendations the academy is making is that any athlete suspected of experiencing a concussion should immediately be removed from play,” says Christopher C. Giza, MD, co-author of the AAN guidelines. “We’ve moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually. There is no set timeline for safe return to play.”

For parents unfamiliar with concussion signs and symptoms, they include:

* Headache and sensitivity to light or sound

* Changes to balance, coordination and reaction time

* Changes in memory, judgment, speech and sleep

* Loss of consciousness or a “blackout” (happens in less than 10 percent of cases)

Removal from play is just the first step in properly treating a concussion. After a player who is exhibiting concussion signs or having concussion symptoms is removed, it’s equally important that the player be examined by a licensed health care professional trained in diagnosing and managing concussions. “Being seen by a trained professional is extremely important after a concussion,” says Jeffrey S. Kutcher, MD, co-author of the AAN guidelines. “If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor.”

If your athlete is diagnosed with a concussion, it’s extremely important to follow the recommendations of the health care professional, and the athlete should not be permitted to resume any sports-related activities until he or she is cleared by a licensed health care professional to do so. Parents, coaches and officials should all work together to see that the health care professional’s recommendations are followed, ensuring the best possible short- and long-term outcome for the athlete.

Parents, coaches and officials should familiarize themselves with concussion protocols before they ever get to the field or court, but the AAN also offers a smartphone app should you need to review them. The Concussion Quick Check app can be downloaded free of charge and provides a handy guide to making sure your athlete gets the proper care.

In addition to emphasizing proper care for athletes exhibiting concussion symptoms, the new AAN guidelines include the following concussion-related findings:

* Among the sports in the studies evaluated, risk of concussion is greatest in football and rugby, followed by hockey and soccer. The risk of concussion for young women and girls is greatest in soccer and basketball.

* An athlete who has a history of one or more concussions is at greater risk for being diagnosed with another concussion.

* The first 10 days after a concussion appears to be the period of greatest risk for being diagnosed with another concussion.

* There is no clear evidence that one type of football helmet can better protect against concussion over another kind of helmet. Helmets should fit properly and be well maintained.

* Licensed health professionals trained in diagnosing and managing concussion should look for ongoing symptoms (especially headache and fogginess), history of concussions, and younger age in the athlete. Each of these factors has been linked to a longer recovery after a concussion.

* Risk factors linked to chronic neurobehavioral impairment in professional athletes include prior concussion, longer exposure to the sport and having the ApoE4 gene.

* Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing (paper-and-pencil and computerized) and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis.

To view the entire AAN concussion report and find more concussion resources, visit www.aan.com/concussion.

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Study: Long-term effects of concussions tested by university student

University students in Georgia are leading an interesting study on the long-term effects of concussions.

From up in the stands on a Friday night, high school football spectators hear it — the grunt of an athlete, the whistle of a referee, the crack of a helmet against another helmet.

Down on the field, the player feels it. Every time he gets tackled to the ground, the player knocks his head against the inside of his helmet. Sometimes he’s fine, but, in less fortunate occasions, he sustains a concussion.

Doug Terry, a third-year Ph.D. student in clinical psychology, and others in the University of Georgia psychology department are studying the effects of those concussions in an experiment he said they hope to finish by the time August rolls around.

“This is a global health problem,” the Long Island, N.Y., native said. “The most common way to get a concussion is a sports-related injury. I’ve worked at Children’s Healthcare of Atlanta and now concussions are becoming an increasingly big concern. There’s almost panic in parents who have children — and children themselves, these days — related to if you get a concussion, what that’s going to mean later in life.”

Their research is based on a study released last fall by the National Institute for Occupational Safety and Health, which found that NFL players are at a higher risk of dying from complications with neurodegenerative diseases than the average population.

Concussions, Terry said, are a probable link to deaths caused by neurodegenerative diseases such as Alzheimer’s and amyotrophic lateral sclerosis.

“What we’re seeing in the NFL players is that they might have gotten a concussion and they recovered,” he said. “But then, 40 years later, they’re getting Alzheimer’s at higher rates or they have memory issues more so than people without concussions.”

So, in conjunction with Stephen Miller, a professor in the department of psychology and the director of the Bio-Imaging Research Center, Terry decided to test the NIOSH conditions in a way that would make the results less exclusive.

“How many concussions is too many?” Terry said. “That’s why I’m looking at a population that typically has fewer concussions than NFL players.”

He revamped his initial experiment so that there was a greater time lapse between sustaining a concussion and the after effects of the injury. This time, he wanted to test men in the age range of 40 to 65 who had, while playing football in high school (and not after), received a concussion.

The important part of the injury history, Terry said, is that the concussion had to be a result of playing football. Anyone who might have obtained a head injury in a car accident or a fall would not fit into the experiment because of the amount of force put on the brain.

“Picture yourself on a football field, getting tackled by somebody and hitting the ground and getting a concussion that way, versus going 50 miles an hour in a car and hitting a wall or another car,” he said. “In one, you’re getting whiplash. You’re going forward and then you’re going back in a car. That type of injury is different than if you’re getting tackled and your head just hits the floor and stops.”

The experiment

Last year, Terry tested the effects of concussions on UGA rugby players. The results were not surprising, he said.

“The guys were still in college, so they had had concussions and recovered from those concussions for at least six months,” he said. “We scanned them and did all of these different memory tasks. In that study, the young rugby players didn’t have any issues related to the concussions they had sustained.”

Miller, Terry’s mentor, said there is a possibility concussions at a young age can cause some cognitive changes that aren’t detected because of the injured person’s “top health.”

“If subtle damage or change occurred, over time it may have either an effect that can no longer be overcome by youth and high health, or an effect that worsens over time, to the point that 20 or more years later it begins to show up,” Miller said. “Of course, a third possibility is that having a series of concussions when you are young has no effect on you when in your 50s and 60s.”

To test those conclusions, Terry and company have combined memory tests and functional magnetic resonance imaging scans. The tasks include tests of working memory, which Terry said was the ability to concentrate on and do several things at once.

“When someone does a working memory task, their brain will use more resources,” he said. “After you get a concussion, your brain uses more oxygen, more neurons are firing and more glucose is used up by the brain. Your brain has to work harder to do the same thing. There’s evidence of that in functional MRI directly after a concussion.”

Patrick Curry, a second-year athletic training master’s student from Durham, Conn., is a UGA athletic trainer who has seen all the concussions sustained by University athletes in the last two years. He introduced Terry to a system, the “NeuroCom Balance Manager,” that can test the effects of concussions.

The benefits of using that machine in addition to the psychological tests Terry runs, Curry said, is that it has more capability than a general assessment.

“It’s an objective measure of balance that uses two force plates to measure your center pressure,” Curry said. “It tests all your systems of balance. It can see if balance is impaired many years after a concussion occurs.”

What Terry said he hopes to find in the experiment is the kind of effect, if any, a concussion has on an individual years after the injury.

Curry said the experiment’s results could have a major effect on the way teams handle concussions.

“The biggest thing we’re looking at right now and the biggest concern in sports medicine is the long term effects of concussions,” he said. “This experiment could be a great way to look at it. It could change how we manage concussions acutely. It could change our return to play criteria after someone sustains a concussion.”

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Study: Concussions Affect Children's Brains After Symptoms Subside

Study shows that concussions continue to affect children after the symptoms go away. Seeking specialty care from a pediatric brain specialist is sensible. JR

Brain changes in children who have sustained a mild traumatic brain injury, or concussion, persist for months following injury -- even after the symptoms of the injury are gone, according to a study published in the December 12 issue of The Journal of Neuroscience. The findings highlight the potential benefit of using advanced imaging techniques to monitor recovery in children following concussions.

Despite growing concerns over the risk of concussions in youth, the majority of research examining their effects on the brain has involved adults. These studies suggest that, among other things, concussions alter the brain's white matter -- the long fibers that carry information from one area of the brain to another. Some recent data suggest the developing brains of children may be more vulnerable to the effects of mild traumatic brain injury.

In the current study, Andrew Mayer, PhD, and colleagues at the Mind Research Network and the University of New Mexico in Albuquerque, New Mexico, specifically studied older children (ages 10-17) with mild traumatic brain injury. They found that structural changes in the children's white matter seen about two weeks after the injury remained evident more than three months later despite the disappearance of symptoms related to the injury.

"These findings may have important implications about when it is truly safe for a child to resume physical activities that may produce a second concussion, potentially further injuring an already vulnerable brain," Mayer said.

The researchers conducted cognitive testing and used an advanced imaging technique known as diffusion tensor imaging (DTI) to examine the brains of 15 children who had recently (within 21 days of injury) experienced a concussion and 15 unaffected children. In the brain, DTI specifically images white matter. During a follow-up visit approximately four months post-injury, scientists repeated cognitive testing and imaging.

Initial testing revealed that children with the mild brain injury had subtle cognitive deficits and changes in white matter compared with healthy counterparts. While the children did not report symptoms of the injury during the follow-up visit months later, DTI revealed that the structural changes to the brain remained.

"The magnitude of the white matter changes in children with mild traumatic brain injury was larger than what has been previously been reported for adult patients with mild traumatic brain injury," Mayer said. "This suggests that developmental differences in the brain or the muscular-skeletal system may render pediatric patients more susceptible to injury," he added.

Based on the imaging data collected during the study, the researchers were able to accurately distinguish the brains of patients who had mild traumatic brain injury from those who were healthy 90 percent of the time. Such findings suggest DTI, which does not require the use of ionizing radiation, could one day be used to diagnose the injury and to better characterize the recovery process in the brain.

Christopher Giza, MD, an expert on developmental brain injury from the Mattel Children's Hospital and the Brain Injury Research Center at the University of California, Los Angeles, who was not involved in the study, noted that while the number of patients in the study was small, the findings mark "an important step forward in our understanding of the effects of mild traumatic brain injury on the developing brain."

"Further work is needed to determine whether the changes in white matter present at four months represent a prolonged recovery process or permanent change in the brain," Giza added. "Determining the duration of the structural changes, and whether these changes have clinical implications, remain critical areas for future studies," he said.

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Cognitive Deficiencies Following Concussion Present After Two Months

This article discusses the cognitive effects of concussions which shows that the negative effects last at least two months.

The ability to focus and switch tasks readily amid distractions was compromised for up to two months following brain concussions suffered by high school athletes, according to a study at the University of Oregon.

Research team members, in an interview, said the discovery suggests that some athletes may need longer recovery periods than current practices dictate to lower the risk of subsequent concussions. Conventional wisdom, said lead author David Howell, a graduate student in the UO Department of Human Physiology, has typical recovery at seven to 10 days.

"The differences we detected may be a matter of milliseconds between a concussed person and a control subject, but as far as brain time goes that difference for a linebacker returning to competition too soon could mean the difference between another injury or successfully preparing to safely tackle an oncoming running back," Howell said.

The findings are based on cognitive exercises used five times over the two months with a pair of sensitive computer-based measuring tools -- the attentional network test and the task-switching test. The study focused on the effects of concussions to the frontal region of the brain, which is responsible for working, or short-term, memory and executive function, said Li-Shan Chou, professor of human physiology and director of the UO Motion Analysis Laboratory.

The study was published online ahead of print by Medicine & Science in Sports & Exercise, the official journal of the American College of Sports Medicine.

"If a person goes back to the playing field without a full recovery, that person is put into great danger of being re-injured," Chou said. "In any given season, if you suffer a concussion, the chances of your suffering a second one is three to six times higher and suffering a third is eight times higher. There are accumulations in this kind of injury. It doesn't go away easily."

A big unknown, the researchers said, is just how serious such injuries are for adolescents, whose brains are still developing. It could be the brain can recover more easily, or such injuries could continue to produce deficits that last a lifetime. "We just don't know," Chou said, adding that most previous studies have involved college-aged athletes and older adults.

Each year, there are 300,000 to 500,000 mild traumatic brain injury incidents, or concussions, with 100,000 tied to football, Chou said. He also cited a 2011 report from the Centers for Disease Control and Prevention that called such injuries a silent epidemic, with sports-related concussions in youths rising by 60 percent in the last decade. Another source of concussions, he added, is improvised explosive devices used in warfare.

Through an arrangement with Eugene-area schools, 20 high school athletes who had suffered a concussion -- primarily football players but also others from soccer, volleyball and wrestling -- were assessed within 72 hours of injury and then again one week, two weeks, a month and two months later. Each of the subjects, whose diagnosis was made by a certified athletic trainer and/or physician, was matched with a healthy control subject of the same sex, body size, age and sport.

"After two months following the concussions, these individuals were still significantly impaired in their executive function, compared to age-matched, activity-matched and gender-matched control populations," said co-author Louis Osternig, professor emeritus of human physiology and a fellow of the American College of Sports Medicine.

Osternig, also a certified athletic trainer, noted that self-reports by the subjects about how they were feeling sometimes were at odds with test results, which continued to show subtle deficits in cognitive functioning. The researchers also noted anecdotal reports from concussed athletes and their parents of declines in academic performance during the two-month period.

Additional data linking the deficits found in cognitive testing to the subjects' gait -- their task-shifting abilities while walking -- currently are being analyzed in the ongoing project, which is funded by the Department of Defense Telemedicine & Advanced Technology Research Center (W81XWH-11-1-0717), National Athletic Trainers Association, Veterans Administration and a translational research award from a joint UO-PeaceHealth Oregon Region collaboration program.

"By using tools from cognitive psychology, neuroscience and human physiology, this interdisciplinary team of scientists is improving our understanding of how brain trauma affects reaction time, and they are helping to create better outcomes for athletes, soldiers and others who are affected by concussions," said Kimberly Andrews Espy, vice president for research and innovation and dean of the graduate school. "UO researchers are working to improve the health and well-being of people in our local communities and throughout the world."

"The brain is the controller of our body movement," Chou said. "If you have a brain injury, are there any differences that we can pick up in the way a subject moves the body? In this lab, we are using motion analysis as a way to detect any deficiencies or abnormalities of body movement."

Chou said that his lab's goal, for now, is to disseminate the findings to the public and to talk to parents, athletic trainers and, perhaps, coaches directly to say: "These are the facts. We may not be able to draw any line on what clinically should or shouldn't be done. However, these are our observations based on our scientific testing."

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Young Athletes and Concussions

This article discusses concussions and the impact concussions have on young athletes, what is being done about concussions, and what should be done in the future.

Young athletes are the focus of new efforts to improve the care of concussions in children and teens, who are more vulnerable than adults to long-term physical, cognitive and emotional problems as a result of the brain injury.

Medical centers including Dartmouth-Hitchcock Medical Center in Lebanon, N.H., Children’s Hospital of Philadelphia and the University of Pittsburgh Medical Center are offering new programs to better educate school nurses, coaches, athletic directors, parents and pediatricians about steps to take to avoid repeat trauma and complications.

CONCUSSION MYTHS AND FACTS

• Myth: Only contact sports put athletes at risk of concussion.
• Fact: Concussions can occur in any sport or recreational activity—even ballet—if there is a violent movement or blow to the head or body that causes the brain to move rapidly inside the skull.
• Myth: You must lose consciousness or black out to have a concussion.
• Fact: Only a small number of concussions involve loss of consciousness.
• Myth: Concussions affect everyone the same way.
• Fact: Genetic differences may account for susceptibility. A history of migraines and weak neck muscles are associated with injury, and girls are more vulnerable than boys.
• Myth: Helmets in football and other activities can protect players.
• Fact: Helmets protect against skull fractures, but don’t always protect against the forces that cause the brain to traumatically move within the skull.
• Myth: You need to repeatedly wake up someone who has had a concussion.
• Fact: Rest is important. Check on concussion victims, but allow them to rest.
• Myth: The effects of a concussion are short-lived.
• Fact:  Concussions can cause cumulative damage to neurons and structural damage to the brain.

Source: Dartmouth-Hitchcock Medical Center, University of Pittsburgh Medical Center, CDC

New research is also leading to a better understanding of concussion, which occurs when a sudden movement or direct force to the head sets brain tissue in motion within the skull. Studies show, for example, that each patient may experience concussion differently, and some patients are more genetically predisposed to sustaining a concussion. Tests are helping identify those patients who may have protracted recovery periods.

“Concussion is a very common injury, and the good news is that most people get better by themselves,” says Michael Lipton, associate director of the Gruss Magnetic Resonance Research Center at Albert Einstein College of Medicine in Bronx, N.Y. “But
there is a group who won’t do as well.”

‘WHO NEEDS TO BE WATCHED’

Dr. Lipton and others have used a special imaging technique to detect a biomarker that may provide a clearer long-term prognosis after a concussion. The advance could help health professionals identify “who needs to be watched more carefully,” he said.

Most states now require students who have had concussions to be kept out of sports until they are cleared by a medical professional. But experts warn that physicians may not be aware of the latest approaches to managing concussions or adhere to protocols for assessing patients and gradually returning them to school and play.

Estimates of the frequency of sports-related concussions in the U.S. run as high as 3.8 million a year. Among children and adolescents, according to the Centers for Disease Control and Prevention, ER visits for sports- and recreation-related brain injuries rose by 60% over the last decade.

Last summer, the CDC established a working group to create a set of guidelines for use in doctors’ offices and emergency departments within the next two years.

In a survey of 145 emergency and primary-care doctors published recently in the journal Pediatrics, researchers at Children’s Hospital of Philadelphia found that doctors didn’t consistently follow assessment guidelines or prescribe proper discharge instructions to concussion patients. These instructions outline such steps as rest; refraining from activity and stimuli such as TV and videogames; and gradual return to schoolwork and play.

Last year, Children’s Hospital trained more than 100 providers in its network in concussion management and assessment. “We have to be very careful and rigorous in the way we evaluate and manage pediatric patients,” says Mark Zonfrillo, lead author of the study.

COUCH POTATO

The University of Pittsburgh Medical Center, which works with physicians and athletic trainers to identify and manage sports-related concussions, offers physical therapy to restore visual function, stamina and balance. Experts there helped develop a computerized test called Impact—for Immediate Post-Concussion Assessment and Cognitive Testing—which measures verbal and visual memory, reaction time and impulse control. More schools now offer such tests to athletes in contact sports before they start play. Cognitive function then can be compared with tests administered after a concussion.

Michael Collins, director of the UPMC sports medicine concussion program, says that if Impact scores fall below a certain level following an injury, there is an 85% chance recovery will take longer. “Those kids have to be managed very carefully,” says Dr. Collins, who is part of  the CDC group working on the new guidelines. One risk is post-concussion syndrome, which includes chronic difficulties such as mood changes, nausea and problems with sleep, thinking, memory and attention.

A second injury sustained during recovery from concussion can result in second-impact syndrome, which can cause brain swelling, bleeding and permanent disability or death, warns Susanna Gadsby, the nurse-coordinator who oversees Dartmouth-Hitchcock’s sports concussion program and its workshops. “Our aim is to help kids get back to play safely, and often just pulling a kid from the field and making them a couch potato for a while is the answer,” she says.

At Hanover High School near Dartmouth last fall, there were six concussions diagnosed in a two-week period during football, soccer and field-hockey season, says athletic director Michael Jackson.

Hanover is one of several high schools and colleges participating in a study at Dartmouth Medical School measuring the impact of blows to the head in athletes. Using sensors implanted in helmets, they hope to better understand, among other things, what kinds of impacts cause concussions and “what it is about a particular impact that gives one person a concussion, while the other bounces up as if nothing happened,” says lead researcher Thomas McAllister.

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