Concussions in the U.S. - Some helpful information on brain injury

This article explains all about concussion in the U.S., how to treat them, and common misconceptions about concussions.

Concussion, sometimes referred to as mild traumatic brain injury, is one of the most commonly encountered sports injuries. Studies vary but rates are estimated at two million sport related concussions per year in the United States. It is also commonly believed that these are under reported injuries due to lack of recognition of the concussion and the desire of athletes to not miss time from their activity.

Research has led to change in our approach to treatment of the injuries. New guidelines do not use a set time away from activity and emphasize a gradual return to play. While concussions often occur from direct contact to the head or face, they may also occur from rotational forces without contact such as a tumbling fall. Although research continues to help understand what happens to the brain in a concussion, it appears that the neurons (brain cells) sustain a small injury that creates an "energy crisis." This generally lasts 7-10 days and physical or cognitive activity during this time period may worsen symptoms and prolong recovery. ...

Collision sports (football, hockey, etc.) generally have the highest overall rates of concussion; however, they can be seen in all sporting activity. Fortunately, the overall rates of concussions are relatively low even in collision sports. Certain risk factors are associated with an increased risk of concussion or prolonged recovery. Genetics, gender, playing position, migraines, history of multiple concussions and mental disorders (depression, anxiety and ADHD) all may play a role in how an athlete is affected by a concussive injury.

However it is still unclear how much influence each of these factors has on an individual athlete's risk. The diagnosis of a concussion can be complex as the signs and symptoms of concussions can be found in many other conditions and there is not a singular test we can use to determine if a concussion has occurred. Sometimes the diagnosis is very straight forward, for example when there has been a brief loss of consciousness, but many times the changes seen in the athlete are very subtle. The diagnosis of a concussion is mainly based on the history and physical examination. Symptoms of a concussion may include headache, dizziness, nausea/vomiting, amnesia, brief loss of consciousness and inability to concentrate. These symptoms may last for several days to a few weeks.

Imaging, CT scan or MRI, rarely indicate concussions, unless there is a finding on examination that suggests a structural injury ( e.g. bleeding or swelling). Newer computerized tests may add value in some cases, but these tests are not used to diagnose concussions and it is unclear if using these tests improve the outcomes of concussed athletes. Previous grading scales used symptoms at the time of the concussion to determine the severity of the concussion. New guidelines now suggest that we not grade concussions at all and that we only determine that a concussion has occurred. The reasoning for this lies in newer research that shows symptoms at the time of the initial injury do not correlate with the severity of the injury and recovery time. Additionally, grading does not change our treatments as resting until symptoms have resolved is the initial treatment regardless of the injury.

Treatment

When an athlete is suspected of having a concussion, they should be removed immediately from competition. Symptoms should be monitored and the athlete should not be returned to competition until they are evaluated by a qualified medical professional. This evaluation should occur as soon as possible. The athlete should be monitored closely for several hours after a concussion. It is important to stress that both physical and mental rest speed the recovery of concussions. It is okay for the athlete to sleep and should avoid over stimulation such as video games or loud crowded activities. Athletes may need to stay out of school or have modified class schedules.

Ask your health care provider for more specific recommendations. Returning the athlete to play starts when the athlete is symptom free. It will take 3-7 days for full return to sports (depending on the sport) with an athlete gradually increasing their activity level every 24 hrs. Returning to class can occur over the same timeframe and athletes should be monitored as well for any increase or recurrence of symptoms. Activity can surface underlying concussion symptoms and athletes should be instructed to notify their coach, trainer or physician if they redevelop any symptoms during the recovery period. This process allows faster and safer return to sporting activity. Computerized neuropsychological testing is sometimes used to help monitor an athlete's progress but is never used on its own to determine a diagnosis or an athlete's readiness to return to play. There are many common misconceptions about concussive injuries.

The following are several myths about concussion:

Every athlete who sustains a hard hit must have a concussion. Although our knowledge about the forces involved in concussion is improving we still have not found a level of force that definitely causes a concussion. At times high forces do not cause an injury and relatively lower ones may. This means that we should not overact to every head impact but also need to listen to athletes who complain of concussive like symptoms after any head contact. Because there is no known force level for concussion in-helmet devices that are marketed to consumers as "concussion alarms," they are not recommended as they will likely lead to both over and under diagnosis of concussive injuries.

Better helmets and mouth guards will prevent concussions. Unfortunately there is no good scientific evidence that helmets of any type (hard shells, soft-padded or head bands) or mouth guards can prevent or reduce the risk of concussions. Hard helmets can reduce the risk of more serious head injuries (bleeding, skull fractures etc.) and should be worn in high risk sports. Mouth guards can prevent dental injuries and should be worn for sports with a high risk of these injuries. Helmet-add ons additionally are not effective in concussion prevention and using these will generally void any warranties associated with the helmet. Risk reduction may be possible in some settings with rule changes (e.g. no hitting from behind in hockey) and behavior changes (e.g. tackling technique in football).

Once you have a concussion you will always be more susceptible to having another one. While there appears to be an increased risk of recurrence in the first few weeks after a concussive injury it is unclear what factors may influence the risk of another injury in the future. Despite being a commonly held belief there is no evidence to suggest that athletes develop a decreasing force threshold after each injury. A few small studies have found the opposite....

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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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Informing does not make parents confident to handle concussions

A survey showed that informing parents does not make them confident enough to treat a concussion.

Many parents whose kids participate in athletics will be asked to sign a waiver about concussion education, but that's not enough to ensure parents are confident about handling the injury, according to a new University of Michigan C.S. Mott Children's Hospital National Poll on Children's Health.

In the poll, about half of the 912 parents of middle and high school children surveyed reported participation in some type of concussion education:

• 23% have read a brochure or online information

• 17% have watched a video or attended a presentation

• 11% have signed a waiver form, with no other educational component

• 49% report no concussion education at all

Concussion education is more common among parents of children who play sports compared to non-sports parents (58% vs 31%).

"It is good news that many parents report they have received concussion education. We found, however, that the format of that concussion education really matters. The way the concussion information is delivered is linked to the parents' confidence about managing their child's injury," says Sarah J. Clark, M.P.H., associate director of the National Poll on Children's Health and associate research scientist in the University of Michigan Department of Pediatrics and U-M Medical School.

"Many schools mandate that a waiver form to be signed, but the danger is that parents will skip over information to get to that required signature line."

The poll showed that 63 percent of parents who watched a video or a presentation rated it as very useful. Forty-one percent of parents who read a brochure or online information rated that as very useful.

However, only 11 percent of parents whose only concussion education was signing a waiver form reported that was very useful.

"If the waiver is done online or on a form returned to school, parents may be left without information at home to guide them if or when their child is injured," says Clark, who is also a member of the U-M Institute for Healthcare Policy and Innovation.

The U.S. Centers for Disease Control estimates that each year, nearly 175,000 children are treated in US emergency rooms for concussions related to sports or recreational activities, including bicycling, football, playground activities, basketball and soccer.

Research has shown that the healing process for a concussion is different for kids than adults and that repeated concussions in a short time period are particularly dangerous.

Parents should get information about when to seek medical attention, monitoring the child's symptoms, and limiting physical activity until symptoms have subsided, says Clark. Health care providers also may recommend limiting homework and other mental activities to allow the brain to heal.

"Parents play a key role in deciding when a child returns to school and extracurricular activities, and concussion education can assist them in making good decisions," Clark says. "So one solution could be to offer multiple education formats to ensure that parents truly hear the concussion information rather than focusing on just signing a form."

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Do helmets protect children from concussions?

This article explains how no helmet can entirely protect a child from concussions.

Children wear helmets when they're scooting down sidewalks, skating, skiing, sledding and playing soccer. You can even buy $40 baby helmets on Amazon, because, according to the product description, "babies will always fall taking their first steps."

Putting aside the debate over whether helmets are truly necessary in all of these situations, there's something about helmets you might not know: They won't protect your kids from common head injuries that may cause long-term problems.

There's no question that helmets save lives by preventing skull fractures and other lethal brain injuries. But according to a 2013 report on youth sports-related concussions by the Institute of Medicine and the National Research Council, "there is limited evidence that current helmet designs reduce the risk of sports-related concussions."

That helmets don't protect against concussions is particularly worrying considering that children and adolescents may be both more vulnerable to concussions and recover more slowly from them compared to adults.

And statistics suggest that concussions are becoming more common among kids. One recent study reported a doubling in concussion-related ER visits by youth between 1997 and 2007. Some of this increase is undoubtedly due to growing awareness about concussions and better diagnostic techniques, but concussions are still believed to be underreported.

There's no good treatment for concussions, other than rest (for days, weeks or months, depending), but this rest is crucial: individuals who get concussions and then hit their heads again before they're fully healed can suffer brain swelling and even die.

Concussions are typically diagnosed based on symptoms -- headaches, dizziness, amnesia, nausea, and vomiting are among them -- but as for what kinds of blows to the head cause them, that's still largely a mystery.

"I couldn't even define the mechanism," explains Adam Bartsch, Director of the Cleveland Clinic's Head, Neck and Spine Research Laboratory.

And we can't come close to designing a concussion-proof helmet, he says, until we understand exactly how concussions happen.

Today's sports helmets are designed to attenuate high-impact linear acceleration forces, which occur in a straight front-to-back line, like "if you hit the head through the center of gravity," explains Robert Cantu, a neurosurgeon at the Boston University School of Medicine and co-author of "Concussions and Our Kids."

Yet most hits to the head, whether they're from falling off bicycles or scooters or from team sports collisions, cause the brain to rotationally accelerate, leading to concussion.

It's just that the linear acceleration is more strongly associated with severe injuries, like cracked skulls, and when the National Operating Committee on Standards for Athletic Equipment was formed in 1969 -- a year in which 38 Americans died playing football -- the goal was to develop helmet standards that would mitigate only the most severe injuries.

And consider the standards set for bicycling helmets by the Consumer Product Safety Commission. Since people bike in different climates and conditions, the CPSC mandates that bike helmets have to pass drop tests from a height of 6 feet at temperatures as high as 127 degrees, as low as 1 degree, and after being immersed in water for up to 24 hours.

Few materials can maintain their performance in such a range of conditions; one that does is expanded polystyrene (EPS), which is the foam that comprises the inner liner of most bike helmets sold today. The problem is that EPS is so strong that it doesn't protect well against low-energy concussion-inducing impacts.

Obviously you can't protect your kid's head from everything. Nor would you want to, really, as over-protective parenting is not without risks itself.

But given the growing medical concern over the dangers of repeated concussions, common sense says that we might be wise to keep our kids' heads from smacking into things more than they absolutely have to. Helmets don't clear us of this responsibility.

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Study: Concussion can mean depression years later

A study done in mice shows that concussions can lead to the development of depression later in life.

A head injury can lead immune-system brain cells to go on "high alert" and overreact to later immune challenges by becoming excessively inflammatory -- a condition linked with depressive complications, a new animal study suggests.

The findings could help explain some of the midlife mental-health issues suffered by individuals who experience multiple concussions as young adults, researchers say. And these depressive symptoms are likely inflammation-related, which means they may not respond to common antidepressants.

An added complication is that aging already increases brain inflammation. So on top of normal aging concerns, people who have had a traumatic brain injury (TBI) experience added inflammation caused by magnified immune responses to so-called "secondary challenges," such as a second head injury, infections or other stressors.

In mice, these high-alert cells in the brain -- called microglia -- had an exaggerated response to an immune challenge one month after a moderate brain injury. This increased brain inflammation corresponded with the development of depressive behaviors that were not observed in uninjured mice.

"If we had waited three, six or nine months, the symptoms probably would have gotten even worse," said lead author Jonathan Godbout, associate professor of neuroscience at The Ohio State University and a researcher in the Institute for Behavioral Medicine Research.

"A lot of people with a history of head injury don't develop mental-health problems until they're in their 40s, 50s or 60s. That suggests there are other factors involved, and that's why we're looking at this two-hit idea -- the brain injury being the first and then an immune challenge. It's as if one plus one plus one equals 15. There can be a multiplier effect."

The research is published online in the journal Biological Psychiatry.

This work applies to concussive brain injuries that result in a diffuse -- or spread out -- trauma to the brain. These are also concussive injuries from which people and animals recover fairly quickly, typically showing no problems with thinking or moving about a week after the injury to the brain.

In the study, researchers compared uninjured mice with mice that had experienced a moderate TBI. Injured mice showed some initial coordination problems, but those resolved within a week.

The injured mice also showed signs of depressive symptoms that improved within one month. Godbout and colleagues attributed those symptoms to the expected neuroinflammation that occurs after a traumatic brain injury. In these mice, most of the inflammation had cleared within seven days.

Thirty days after injury, researchers examined the brains of the injured mice to determine whether immune cells had remained on high alert since the injury. As expected, the injured brains contained microglia that had stayed in a "primed" state -- meaning they were on standby to respond to a challenge to the immune system. The cells in the brains of uninjured mice did not have the same characteristics.

Under normal circumstances, microglia are the first line of defense and help protect the brain after injury or infection by making proteins and other chemicals that generate just enough inflammation to repair the problem. When they are primed, however, these cells are in a higher state of alert and when they are activated, they generate an amplified immune response that lasts longer than necessary. When these systems are activated with nothing to fight, the circulating chemicals and proteins generate excessive inflammation.

"The young adult mice that have a diffuse head injury basically recover to normal, but not everything is normal. The brain still has a more inflammatory makeup that is permissive to hyperactivation of an immune response," Godbout said.

At 30 days after TBI, the mice were injected with lipopolysaccharide (LPS) -- the dead, outer cell wall of bacteria that stimulates an immune reaction in animals. Tests showed that over the course of 24 hours after the injection, TBI mice were much less social than uninjured mice -- one type of depressive symptom in these animals. The brains of the TBI mice also had dramatically higher levels of two inflammation-related proteins than did brains from normal mice.

Seventy-two hours after the LPS challenge, injured mice showed additional depressive symptoms, including minimal interest in sugar water -- a sign that they avoided what is typically a pleasurable activity. They also showed increased resignation, or a sign of "giving up."

Uninjured mice behaved normally and the levels of inflammatory proteins in their brains had returned to baseline over the same time period.

"These results tell us the TBI mice are having an amplified and prolonged activation of microglia, and that was associated with development of depressive symptoms in the mice," Godbout said.

His lab is now investigating potential treatments that could either prevent the priming of microglia immediately after injury or later reverse the high-alert characteristics of these cells.

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Youth concussions in sports

This article discusses the basics of youth concussions, discusses the signs and symptoms, and provides resources for more information.

Athletes sometimes joke about “getting your bell rung” or feeling a “stinger” after taking a hit to the head during sports. However, adolescent concussions are common and can have serious consequences.

WHAT IS A CONCUSSION?

A concussion is a type of brain injury. The brain is made of soft tissue and is surrounded by a cushion of spinal fluid. The skull surrounds the brain and protects it. A person can injure their brain by getting hit on the head, or even the body, resulting in the brain moving around in the skull. This can lead to bruising of the brain, damage to blood vessels, and injury to nerves. People can get a concussion from a fall, a car crash, or a sports injury.

CONCUSSIONS AND SPORTS

One of the most common ways children and adolescents get concussions is through sports injuries. A recent review estimated that up to 3.8 million recreation- and sports-related concussions occur each year in the United States. The sport with the highest risk of concussion in high school is football. In girls' sports, the rate of concussion is highest in soccer and basketball. Girls have a higher rate of concussion than boys when they are in similar sports. Young athletes' brains are still developing, thus they may be at higher risk for the effects of a concussion. The way in which the injury happens may be very important in predicting how serious the injury will be. This was described in a study in this month's Archives.

SIGNS AND SYMPTOMS

The signs and symptoms of concussion fall into 4 categories:

• Physical: Headache is the most frequently reported symptom of a concussion. Nausea and vomiting can also occur. Problems with balance, vision, and fatigue are also common.
• Cognitive: A feeling of mental “fogginess” or feeling “slowed down” are also common. Loss of memory is a symptom that suggests a more serious injury.
• Emotional: Symptoms may include irritability, sadness, or nervousness.
• Sleep: Symptoms may include feeling drowsy and sleeping more than usual. However, some patients sleep less than usual and have difficulty falling asleep.

CONCUSSION: TRUE OR FALSE

• If my child is in a soccer game and hits his head, the concussion should be “toughed out” until the end of the game.
  False. Children or adolescents who have a concussion, or parents or coaches suspect they have one, should always be evaluated by a qualified health care provider before returning to play.
• You do not have a concussion if you did not lose consciousness.
  False. A concussion often does not result in loss of consciousness; brain injury occurs even without this.
• My child had a concussion and her pediatrician said she should take a break from playing basketball and from playing video games.
  True. After a concussion, all athletes should be restricted from physical activity until they have no symptoms both with rest and with exercise. Physical and cognitive exertion should be avoided. Activities such as doing homework, playing video games, using a computer, or watching television may worsen symptoms. A return to full activities should only occur under the guidance of a qualified health care provider and should stop if symptoms return with activities.
• A concussion can take weeks or even months to fully recover from.
  True. Symptoms of a concussion usually resolve in 7 to 10 days, but some athletes may take weeks or months to fully recover.

FOR MORE INFORMATION

American Academy of Pediatricians
http://aappolicy.aappublications.org/cgi/content/full/pediatrics;126/3/597

INFORM YOURSELF

To find this and other Advice for Parents articles, go to the Advice for Parents link on the Archives of Pediatrics & Adolescent Medicine website at http://archpedi.ama-assn.org/.

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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: 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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