Fresh Efforts to Improve Teens' Concussion Care

At ice hockey camp two summers ago, goalie Beth Potter slammed her head into the ice when she dived to block a shot, sustaining a concussion with aftereffects that trouble her to this day.

Young athletes like Ms. Potter, now 18, 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.

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, but there is a group who won't do as well," says Michael Lipton, associate director of the Gruss Magnetic Resonance Research Center at Albert Einstein College of Medicine in Bronx, N.Y.

Dr. Lipton and others have identified a biomarker in the brain with a special MRI technique that may predict long-term prognosis after a concussion, which he says could help identify "who needs to be watched more carefully." More details on the technique are due to be released at the annual meeting of the Radiological Society of North America next week.

Most states now require students who have had concussions to be kept from sports until 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, emergency-department visits for sports- and recreation-related brain injuries rose by 60% over the last decade. The CDC established a working group in July 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 last week in the journal Pediatrics, researchers at Children's Hospital of Philadelphia found doctors didn't consistently follow assessment guidelines or prescribe proper discharge instructions to concussion patients. These instructions outline such steps as rest, freedom from activity and stimuli such as TV and videogames, and gradual return to schoolwork and play.

Earlier this 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.

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 neurocognitive 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 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 also a member of the CDC guidelines working group. 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.

Rest without TV and texting helped Ms. Potter recover after her concussion on the ice. In the first two days after her injury, she felt listless and foggy. Her mother, Holly Potter, says it was clear something was seriously wrong when Beth put a handful of pasta into a pot without water on the stove, turned on the burner and walked away. Her doctor recommended rest in a cool, dark room with no stimuli. She began to feel better, though at school she found it hard to follow her teachers. Over the next five months, she combined a gradual return to school with periods of rest and solitude, and physical therapy to help regain balance.

Ms. Gadsby at Dartmouth-Hitchcock administered follow-up Impact tests to compare with a baseline test Ms. Potter had before her concussion. Now a senior at Hartford High School in Vermont, she has been able to return to playing hockey, but still finds herself occasionally struggling to express her thoughts. She has words of caution for her peers: "I know how hard it is to be told you can't play, but don't be upset, and realize they are doing it for your own good if you might have a concussion," she says.

In the past, some doctors advocated removing children from athletics after repeated concussions. However, "if we manage concussions wisely and safely and make sure patients have all their faculties, we shouldn't have to keep kids from sports," says Keith Loud, section chief of general pediatrics at Dartmouth-Hitchcock.

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 on person a concussion, while the other bounces up as if nothing happened," says lead researcher Thomas McAllister.

Concussion Myths and Facts

• Myth: Contact sports are the only ones that 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

By: Laura Landro, Wall Street Journal
Reviewed / Posted by: Scott W Yates, MD, MBA, MS, FACP

© Center for Executive Medicine 2018                    site map