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Current Concepts in Concussion: Initial Evaluation and Management

Current Concepts in Concussion: Initial Evaluation and Management

Am Fam Physician. 2019 Apr 1;99(7):426-434

Author disclosure: No relevant financial affiliations.

Mild traumatic brain injury, also known as concussion, is common in adults and youth and is a major health concern. Concussion is caused by direct or indirect external trauma to the head resulting in shear stress to brain tissue from rotational or angular forces. Concussion can affect a variety of clinical domains: physical, cognitive, and emotional or behavioral. Signs and symptoms are nonspecific; therefore, a temporal relationship between an appropriate mechanism of injury and symptom onset must be determined. Headache is the most common symptom. Initial evaluation involves eliminating concern for cervical spine injury and more serious traumatic brain injury before diagnosis is established.

Tools to aid diagnosis and monitor recovery include symptom checklists, neuropsychological tests, postural stability tests, and sideline assessment tools. If concussion is suspected in an athlete, the athlete should not return to play until medically cleared. Brief cognitive and physical rest are key components of initial management. Initial management also involves patient education and reassurance and symptom management. Individuals recover from concussion differently; therefore, rigid guidelines have been abandoned in favor of an individualized approach. As symptoms resolve, patients may gradually return to activity as tolerated. Those with risk factors, such as more severe symptoms immediately after injury, may require longer recovery periods. There is limited research in the younger population; however, given concern for potential consequences of injury to the developing brain, a more conservative approach to management is warranted.

Mild traumatic brain injury, also known as concussion, accounts for 80% to 90% of traumatic brain injuries and is recognized as a major national health concern.17 Whereas 2.8 million traumatic brain injuries were reported in 2013,8 estimates suggest up to 3.8 million occur annually.4,7,9. Concussion diagnosis and management can be challenging, complicated by the lack of a universal definition.2,6,10 No single objective measure or combination of measures for diagnosis and no definitive evidence-based treatments exist. Return-to-activity and return-to-play decisions are limited by a shortage of prospective data.6 Physicians must rely on expert guidelines and available assessment tools with clinical judgment for diagnosis and treatment.

therudedogshow@hotmail.comCurrent Concepts in Concussion: Initial Evaluation and Management
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A quarter of Americans have had a concussion, and we’re still far from understanding its consequences.

A quarter of Americans have had a concussion, and we’re still far from understanding its consequences.

At the end of the third quarter of the fantastic Notre Dame at Texas college football season opener on September 4, there were about 30 seconds left.

Irish wide receiver Torii Hunter Jr. leapt up to catch what looked like a touchdown pass that would have given Notre Dame the lead. But Texas defensive back DeShon Elliott slammed into Hunter with a hit that at least appeared to to make direct contact with his helmet. The ball fell to the ground and Hunter didn’t get up.

After several minutes of checking to ensure he could still move his arms and legs, the medical team helped him to his feet and walked him to the locker room. The redshirt junior team captain is now in what’s known as the concussion protocol, which means that he’s supposed to return to baseline levels of cognitive performance and balance before slowly ramping up physical activity again.

It’s unclear whether or not Hunter will be cleared to play in the Irish home opener against Nevada on September 10.

We now pay a lot more attention to head injuries in football and other sports, as we’re more aware now of the potential long term consequences than we have ever been. But that doesn’t mean we are anywhere close to figuring out what to do about these injuries.

Hunter’s return is unclear in part because every individual hit to the head is unique, as is the recovery process. But the issue is also something much larger: We still don’t understand nearly as much as we would hope to about brain injuries, despite the fact that they are astonishingly common.

“Part of the biggest problem that we have is that we still don’t know exactly what a concussion is,” Dr. Chad Asplund, medical director of athletics sports medicine at Georgia Southern University, tells Business Insider. We know how concussions happen and we’ve observed a number of different symptoms triggered by brain trauma, but we still don’t know exactly at what point these injuries (or smaller sub-concussive hits) lead to permanent damage.

Almost a quarter of Americans report having suffered a concussion, according to a recent NPR-Truven Health Analytics Health Poll.

therudedogshow@hotmail.comA quarter of Americans have had a concussion, and we’re still far from understanding its consequences.
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Concussion expert says extent of brain damage in youth football players ‘took my breath away’

Concussion expert says extent of brain damage in youth football players ‘took my breath away’

What you won't hear when you go to the "Big Box" healthcare facilities

When it comes to concussions in football, most of the research and regulations have occurred on the college and professional levels, where the hits are the hardest and the spotlight is the brightest.

But now, top researchers are focusing their efforts on the next generation of football players — those currently playing on teams in high schools, middle schools, and pee-wee leagues across the nation.

In the past three years alone, 47 kids have died playing football. Seventeen of those deaths are directly related to head injuries sustained in practice or during games.

In the latest episode of HBO’s Real Sports with Bryant Gumbel, Chris Nowinski, co-founder and executive director of the Concussion Legacy Foundation, and Dr. Ann McKee, director of the Chronic Traumatic Encephalopathy (CTE) Center at Boston University, talked to HBO’s Bernard Goldberg about the research they have done on the brains of children who play tackle football. (The results of the research will be published this fall.)

“I’ve looked at brains of young teenagers and seen damage that I’ve never seen before,” McKee said. “And it came from football impact injuries. Took my breath away, I can’t believe it.”

Nowinski said that each additional year of playing football increases the chance that a person will develop CTE, the degenerative brain disease caused by repeated blows to the head that can lead to dementia, depression, and even death. Last year, evidence of CTE was found in a total of 87 of 91 deceased former NFL players tested by McKee and her team at the Department of Veteran Affairs and Boston University.

While the impact of football on younger brains hasn’t been studied as comprehensively, scientists at the Mayo Clinic Brain Bank last year discovered evidence of CTE in 21 out of 66 brains they studied that belonged to males who played contact sports when they were young. Perhaps most alarmingly, they studied 198 brains in the bank that had zero documented history of participating in contact sports, and none of those brains showed signs of CTE.

So while the research is still in the early stages, the connection between contact sports in youth and CTE later in life is pretty clear.

“You have to say it simply: It’s a bad idea to hit a child in the head 500 times,” Nowinski said.

Even though players in youth leagues aren’t as strong and fast as players in college and the pros — and therefore the hits sustained theoretically aren’t as hard — brain damage in young players could impact the overall development of a brain.

There have been some initiatives to try and reduce the possibility of brain damage, such as Heads Up Football, a program funded by the NFL and overseen by USA Football, the governing body of youth football in the United States. Initial research showed that Heads Up Football was reducing the rate of concussions by 29 percent, but this summer, the New York Timesreported that those statistics were only preliminary findings. Ultimately, after the study was complete, it was concluded that Heads Up Football did not reduce the risk of concussions at all.

“I’ve looked at brains of young teenagers and seen damage that I’ve never seen before.”

According to Dr. McKee, there is no proof that programs such as Heads Up football are working, and any claims to the contrary by USA Football are misleading.

“There’s no evidence that they’re making the game safer,” she said. “And they’re sort of saying that you can play football at that age and be safe, and that’s not true.”

So while research is conducted and governing bodies look for solutions (or claim to look for solutions at least), millions of young people continue to play full-contact tackle football on a regular — sometimes unlimited — basis. In an effort to reduce brain injuries, the NFL has reduced full-contact practice to once a week, and the NCAA only permits two such practices a week. But there are no corresponding federal guidelines for high school football or below.

“[T]he players who need the protection most are getting it the least,” Terry O’Neil, a former NFL producer, said on HBO.

AdminConcussion expert says extent of brain damage in youth football players ‘took my breath away’
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Curious about concussions?

Curious about concussions?

 

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Football season has begun, reviving concern and discussion over sports-related concussions.

The American Academy of Pediatrics defines a concussion as a direct hit to the head or jarring blow to the body that gets transmitted to the head, resulting in a rapid onset of short lived impairment of neurological function. However, some controversy surrounds even this definition. So I reached out to Jessica Little, PhD, director of clinical research and operations at the Stanford Concussion and Brain Performance Center, to learn more about concussion research and Stanford’s clinical study of teenage athletes.

What should we know about concussions?

I think it’s important to note that concussions are still not well understood. There are hundreds of different definitions of ‘what is a concussion’ and there is currently no single evidence-based consensus on how to identify and treat concussions.

Research has shown that one of the biggest risk factors for sustaining a concussion is a history of having a prior one. There is a ‘window of vulnerability’ — the concept that a person experiencing symptoms of concussion is more vulnerable to incurring a second concussion during this time, as the brain has not yet fully recovered. If a truly concussed athlete has problems paying attention or is not coordinated, they can then be vulnerable to another injury. Protocols are often used to track signs and symptoms of concussion, and athletes are not allowed to return to play until these have resolved. However, it would be helpful to have more precise ways to measure attention and coordination on the sidelines to keep impaired athletes out of contact sports until those skills recover.

The vast majority of people with a concussion recover fully after the injury, though not all symptoms may improve at the same rate and everyone recovers a little differently.

Describe your clinical study for athletes 12-17 years of age.

Our study just closed recruitment, and we’re prepping all the data for analysis, so this is an exciting time. The study was called EYE-TRAC Advance, short for Eye-Tracking Rapid Attention Computation. Our lab used a specific type of eye-tracking called ‘circular smooth pursuit’ where an athlete follows a dot that moves at predictable speed around a circle. The eye-tracking was in the form of custom-designed portable ‘goggles,’ using built-in cameras and infrared pupil detection.

Our hypothesis is that people without a concussion can ‘sync-up’ with the way the dot is moving pretty easily, while a person with a concussion has a disruption in their ability to focus and pay attention. You often hear people saying that they feel ‘off’ or ‘out of sync’ following a concussion, and we’re trying to quantify that experience. For the study, we baseline tested athletes (before sports participation) with the eye-tracking, as well as other neurocognitive tests that measured things like attention and reaction time. If the athlete later got a concussion, we tested them again as soon as possible and again at 1, 3 and 12 months after the injury. In this way, we’re able to get a clear picture of how their brain recovered over time.

Overall, we reached out to more than 60 different organizations and recruited more than 1,400 people. We had a specially outfitted ‘mobile testing center’ RV. This allowed us to literally drive up to the side of an athletic field and perform the testing on-site at the school or organization, which really reduced common barriers to participating in a research study, such as the costs and time associated with transportation to and from appointments.

Can technology play a significant role in preventing concussions?

A lot of current technologies focus on diagnosing a concussion, but there are far fewer that actually focus on preventing concussions. There are some technologies that measure an athlete’s gait and vestibular-balance ability. If there are impairments, the athletes can be provided skill training to improve any deficits, thus reducing the risk of injury. Other technologies, such as helmet technologies, may be helpful in reducing the instance of skull fractures and other serious injuries, but they haven’t yet proved effective at preventing a concussion — that is caused more by brain rotation, which a helmet can’t fully protect against. One possible preventative solution could come from a neck device that stabilizes the rotational forces while still allowing neck movement at low accelerations, so that athletes can move about freely until it senses a potentially dangerous level of force.

Are there issues with under-reporting concussions?

Historically, there have been some issues with individuals under-reporting symptoms that would lead to a diagnosis of a concussion. This is often motivated by the idea that they should ‘suck it up’ or ‘don’t want to let the team down’ or by the fact that their ability to perform athletically is tied to keeping an athletic scholarship. There is research happening in the field right now trying to figure out the best way to dismantle these types of beliefs and make it more likely that athletes can be properly identified, given the treatment they need, and hopefully continue to safely engage in their sport.

Previously: Building a concussion-proof helmet: A Stanford bioengineer shares his findings at TEDxStanfordStanford bioengineers and clinicians team up to shed light on how concussions affect the brain and Forces at work in concussions more complicated than previously thought, new Stanford study reveals
Photo by Steve – Body Slam

Maria CaligiuriCurious about concussions?
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