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Daily Dose

New Concussion Guidelines

1:30 to read

A really interesting study was published in Pediatrics online entitled “Benefits of Strict Rest After Acute Concussion”.  The guidelines for treating a concussion continue to be debated and that is what makes this study thought provoking.  

This was a “randomized controlled study”  which followed 88 patients between the ages of 11 and 22 years who had been diagnosed with a concussion.  45 of the patients were given instructions for 5 days of strict rest at home with no school, no work and no physical activity.  They were then allowed to have a “stepwise return to activity”.  The other 43 patients were told to “rest” for 1-2 days after which time they could  return to school also follow a “stepwise return to activity”.

Interestingly, there was no clinically significant difference in the  neurocognitive or balance outcomes between the two groups.  In fact the group that was “advised to rest for 5 days” reported more daily post concussive symptoms and slower resolution of symptoms than those who were told to rest for 1-2 days.  

This was a small study and does not mean that everyone should be treated the same way. In fact, when seeing a patient who has sustained a concussion each person seems to be a bit different.....as one could expect when discussing a “brain injury”.  No two brains are exactly alike...at least for the time being...who knows what will happen one day with genetics

In my own limited practice I have found that “very few” tweens and teens subscribe to the complete rest theory...that is no school, but also no TV, no computer and no videos or smart phones....WHAT??? No social media for 5 days?  You would have to put most of them on an isolated “post concussion island” to ensure they disconnect.  

The study authors also wondered if patients reported more symptoms after having strict rest recommended.  It seems plausible that I too might notice a few more symptoms when just sitting there wondering if my head hurts or if I seem to be more fatigued.

Subjective symptoms are always difficult to quantify...which makes treating a concussion more problematic.  I think erring on the conservative side and restricting “return to play” for a longer period seems to be of more importance than any other recommendation, including “5 days of strict rest”. In the meantime this is an interesting study....with more data to surely follow. 

 

Your Teen

Concussions May Affect Kid’s Academic Performance

2:00

Can a concussion affect your child ‘s academic performance? According to a new study it might, depending on two factors - the severity of the concussion and the grade level of your child.

A concussion is a brain injury caused by a fall or blow, jolt or bump to the head that causes the brain and head to move back and forth rapidly. While most recover from mild concussions quickly, the young and the elderly can have symptoms that last for days or weeks.

Researchers from the Children's National Health System, George Washington University School of Medicine and Brody School of Medicine at East Carolina University studied 349 students ages 5 to 18 to find out what happened to their academic performance after concussions. They divided the students into those who were continuing to experience problems following head injuries and those who were fully recovered, and asked the students and their parents to fill out questionnaires about their academic performance.

The study found that the severity of the concussion symptoms was directly related to the degree of academic problems among all grade levels. Eighty-eight percent of the children who were not fully recovered still had problems with concentration, headaches and fatigue. Seventy-seven percent of those same children had problems taking notes and found themselves spending more time on homework and having problems studying for exams and quizzes.

High school students reported having the most learning problems, significantly more than middle or elementary school children.

The authors say that their findings suggest that school systems and medical professionals should be working together to support students who are still in the recovery phase.

"Our findings suggest that these supports are particularly necessary for older students, who face greater academic demands relative to their younger peers," the study's authors say.

The signs and symptoms of a concussion can be subtle and may not be immediately apparent. Symptoms can last for days, weeks or even longer.

The Mayo Clinic says that common symptoms after a concussive traumatic brain injury are headache, loss of memory (amnesia) and confusion. The amnesia, which may or may not follow a loss of consciousness, usually involves the loss of memory of the event that caused the concussion.

Signs and symptoms of a concussion may include:

•       Headache or a feeling of pressure in the head

•       Temporary loss of consciousness

•       Confusion or feeling as if in a fog

•       Amnesia surrounding the traumatic event

•       Dizziness or "seeing stars"

•       Ringing in the ears

•       Nausea

•       Vomiting

•       Slurred speech

•       Delayed response to questions

•       Appearing dazed

•       Fatigue

Some symptoms of concussions may be immediate or delayed in onset by hours or days after injury, such as:

•       Concentration and memory complaints

•       Irritability and other personality changes

•       Sensitivity to light and noise

•       Sleep disturbances

•       Psychological adjustment problems and depression

•       Disorders of taste and smell

Symptoms in infants and toddlers can be difficult to recognize because these little ones are unable to communicate how they feel. However, there are nonverbal clues of a possible concussion. These are:

•       Appearing dazed

•       Listlessness and tiring easily

•       Irritability and crankiness

•       Loss of balance and unsteady walking

•       Crying excessively

•       Change in eating or sleeping patterns

•       Lack of interest in favorite toys

Concussions should always be treated seriously even when a child doesn’t seem to be showing physical or mental symptoms. If you suspect your child may have a concussion seek a professional diagnosis to make sure.

Sources: Sandee LaMotte, http://www.cnn.com/2015/05/11/health/concussions-academic-problems/index.html

http://www.mayoclinic.org/diseases-conditions/concussion/basics/symptoms/con-20019272

Your Child

Concussions May Last Longer in Girls

2.00 to read

New research suggests that girls who suffer a concussion may have more severe symptoms that last longer compared to boys.

No one seems to know why there is a difference, but other studies have come to the same conclusion.

"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.

In the new study, Fehr tracked patients from 10 to 18 years old. All were 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.

Girls reported more severe symptoms and 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.

The length of time it took for patients to fully recover from concussion is quite a bit longer than people usually think.

"Commonly you hear that seven to 10 days [for recovery] is average," Fehr said.

The patient’s who were part of this study went to concussion clinics, so their injuries may have been more acute.

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.

Fehr will present the findings at the American Medical Society for Sports Medicine this week. Studies presented at medical meetings are typically viewed as preliminary until published in a peer-reviewed journal.

Whether it’s a boy or a girl that suffers a concussion, 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 American Academy of Pediatrics.

Anyone with a history of concussion is also at higher risk for another injury.

Source: Kathleen Doheny, http://www.webmd.com/brain/news/20140410/girls-suffer-worse-concussions-study-suggests

Your Child

Concussion Symptoms Continue Long After Injury

2.00 to read

Symptoms such as headache, dizziness and blurry vision typically show up right after a child suffers a concussion. In a study from the emergency medicine division at Boston Children’s Hospital, researchers have found that emotional and mental symptoms, such as irritability and frustration may show up much later and hang around longer.

 "Patients and their families should expect the physical symptoms that they experience after a head injury to get better over the next few weeks, but that emotional symptoms may come on later, even as the physical symptoms subside," said lead researcher Dr. Matthew Eisenberg.

"Only by knowing what symptoms can be expected after a concussion can we help reassure patients and families that what they experience is normal, know when to seek additional help, and make sure that children are taking appropriate precautions in regard to school and sports to achieve a full recovery," Eisenberg added.

For the study, 235 children and young adults, ages 11 to 22, who were treated for concussion at a pediatric ER, answered questionnaires about their injury and were followed for three months after their visit. Patients were monitored until all their symptoms were gone. During that time they were asked about symptoms, sports activity and school and athletic performance.

The most common physical symptoms were headache, dizziness and fatigue, which tended to start right after the injury and got better over time. Researchers found that most of the children also had mental symptoms, such as difficulty concentrating and taking longer to think.

Eisenberg’s team noted that a majority of the children recovered within two weeks, however, 25 percent still had headaches a month after their injury. More than 20 percent said they were fatigued and 20 percent reported taking longer to think.

For many, emotional symptoms -- such as frustration and irritability -- were not as common right after the injury, but developed later, the study authors noted.

Dr. John Kuluz, director of traumatic brain injury and neurorehabilitation at Miami Children's Hospital, said, "It takes longer than people think to fully recover from a concussion. My experience is that kids who still have symptoms two weeks after a concussion are going to have a very hard time, and it's going to be a struggle to get them to the point where they have no symptoms."

Kuluz recommends that parents make sure concussion symptoms are not ignored and their kids receive prompt and continued treatment. He suggests physical therapy to work on balance and helping with any vision problems.

He also recommends keeping children out of school for a couple of days after the injury and then gradually letting them get back to normal activities.

Kuluz tries to get kids back to school for half a day or as much as they can tolerate until they get better. Children should not start sports again until all symptoms have disappeared and then only gradually, he added.

This study was published online and in print in the journal Pediatrics.

Another recent study looked at the effects of concussion and years of repeated hits to the brains of college football players.

Researchers found that players who had been diagnosed with concussions and those who had been playing football for years had smaller hippocampuses – a part of the brain that is critical to memory. A smaller hippocampus has been linked to depression, schizophrenia and chronic traumatic encephalopathy (CTE).

The symptoms of CTE, which tend to set in years after the last traumas, often include memory loss, aggression and dementia.

“Boys hear about the long-term effect on guys when they’re retired from football, but this shows that 20-year-olds might be having some kind of effect,” said Patrick Bellgowan, the study’s senior author from the Laureate Institute for Brain Research in Tulsa, Oklahoma.

Concussion studies seem to be popping up everywhere, and for good reason. For too many years, a concussion injury wasn’t given much attention. The common train of thought was that if you play rough sports and you get hit - you shake it off and get back in the game. That philosophy applied whether you were 10 or 30 years old.

Then professional players began to exhibit early onset dementia and depression. Teens began to complain of constant headaches and feeling out of sorts. College players had difficulty concentrating and vision problems.

Parents demanded answers and researchers began looking at concussion and its long-term impact on the brain. The new studies shed a bright light on why these symptoms were troubling.

Most young athletes will not become professional players in their chosen sport or even play on college teams. Eventually, the helmets and pads will be passed on to the next group of excited young athletes and children will choose other activities or graduate into   the “real world”.

What these types of studies tell us is that long after the games are over, children who suffer concussions may experience serious long-term effects.

The symptoms can be so similar to typical teen behavior that they get overlooked. Kids get headaches, they get tired, they forget things and they have emotional outbursts. But if your child has suffered a concussion or even a very hard hit and you notice these symptoms don’t go away, take him or her to see a concussion specialist. They may or not be related to a more serious brain injury, but a missed opportunity for treatment may change your child’s future in ways that no one ever expected.

Sources: Steven Reinberg, http://consumer.healthday.com/general-health-information-16/injury-health-news-413/kids-concussion-symptoms-can-linger-long-after-injury-687715.html

Andrew M. Seaman, http://www.reuters.com/article/2014/05/13/us-brain-health-football-idUSKBN0DT24720140513

 

 

 

Your Child

Concussions May Have Long Term Impact on Kids’ Mental Health

1:45

There’s been a tremendous amount of information about concussions in the news lately. One question many parents want answered is, if my child suffers a concussion could it have an impact on his or her mental, physical or intellectual health for the rest of their lives?

The answer is yes according to a recent study, and for kids who have had more than one concussion; the risks are even higher that they will suffer repercussions into adulthood.

A report released by the health insurer, Blue Cross Blue Shield, said diagnosed concussions among people under the age of 20 climbed 71 percent between 2010 and 2015. Part of that increase may be attributed to an improved awareness of the dangers of concussions, prompting coaches and parents to seek medical attention for athletes and kids.  However, the high numbers also suggest that more children are experiencing head injuries than in the past.

The data also showed that twice as many boys were diagnosed with concussion than girls, although the rates for girls increased by 119 percent during the dates examined.

While more general information about concussion is becoming abundant, the effects on the health of children into adulthood have largely remained unknown.

For the new study looking into the long-term effects, multiple data sources were reviewed including a valuable collection of records from Sweden.

A plethora of linked registries in that nation contain information about people’s medical and hospital visits, socioeconomic status, education, physical disabilities and other aspects of their lives, says Dr. Seena Fazel, a professor of forensic psychiatry at Oxford and the new study’s senior author. The registries also allow researchers to compile information about family members.

In this case, the scientists concentrated on all Swedes born between 1973 and 1985 and looked for those who had experienced a head injury of some kind before the age of 25. More than 104,000 people qualified. Researched reviewed data about these people for 40 years.

Along with each patient, researchers also compiled similar medical records for a sibling who had not been diagnosed with a head injury and compared the results between family members and the total population of the country.

The results of the study were unsettling. They found that young people who had experienced a single diagnosed concussion were more likely to be receiving medical disability payments as adults, to have at some point sought mental health care, were less likely to have graduated from high school or attended college and were twice as prone to die prematurely than their uninjured sibling.

If the patient had experienced more than one concussion while young or if the brain injury was more severe than a concussion, the possibility of physical and psychological problems during adulthood increased.

While the results of the study were disconcerting, there was also good news in the report. Not everyone who had a concussion or brain injury as a child or teenager experienced mental or intellectual problems -related to the brain injury - as an adult.

“The majority of individuals who had diagnoses of brain injury in our study did not experience adverse outcomes,” Dr. Fazel says.

Unfortunately, it is impossible at the moment to identify which children or teenagers who experience head trauma may be most at risk of struggling in later life and which will instead recover without apparent complications, he says.

The overall message from this study is that all steps should be taken to prevent childhood head injuries.

If a young person does suffer head trauma, he continues, more and longer-lasting monitoring is also probably a good idea. Such monitoring may be especially important if the child shows any signs of “a decline in psychosocial performance,” Dr. Fazel says, such as a drop in grades or a change, even subtle, in personality. A neurologist can provide useful assessments, and regular follow-up neurological assessments may need to be continued, even into adulthood.

The study was published online in the journal PLOS Medicine.

 Story source: Gretchen Reynolds, http://www.nytimes.com/2016/10/05/well/move/a-single-concussion-may-have-lasting-impact.html?WT.mc_id=SmartBriefs-Newsletter&WT.mc_ev=click&ad-keywords=smartbriefsnl

Daily Dose

Parents Need To Take Concussions Seriously

Dr. Sue explains why parents need to take concussion seriously. They are a brain injury.I have blogged previously about the latest recommendations concerning concussions and restrictions on activity after sustaining a  concussion. This subject has been in the news a great deal lately, not only within the medical community, but also within the NFL and other major sports groups.

There is more and more data to show that concussions in and of themselves are dangerous, but that repetitive concussions may cause even greater damage to the brain, especially to the still developing brain of young athletes. I just saw an eleven year old boy who is a soccer play, actually, he is the goalie. He was at school, just playing around in the gym, when he sustained a concussion after running into another child head on and falling backwards.  The boy remembered falling, but shortly thereafter he became disoriented, could not take a test due to the fact that his memory was impaired, and subsequently vomited. His concerned parents brought him to my office to be evaluated.  By the time I saw him he was feeling better, and he had a normal neurological exam. Based upon the history of his injury he was diagnosed with a concussion.  Because of this he and his parents were advised that he not participate in sports for a minimum of a week.  Of course, as it would turn out,  his school soccer team was supposed to be in the State championship game in 48 hours.  Their team was 92 -0.  After much discussion and a conversation with his coach the parents we all agreed that he would not play. The following day, I received an email from his father who felt that his son was doing well and was “back to normal”.   He had been re-thinking the issue of his son not playing and wanted me to reconsider my instructions for his son not to play. He even noted that he himself had played college soccer and had often played after suffering a concussion.  He felt that if his son played (if he was absolutely needed to secure a win) and did not do “headers” that he would be okay. What was he thinking?  I don’t really think he was thinking about anything other than his son’s team winning a State championship. He seemed to have tunnel vision, and could not see that there would be many more soccer games in his son’s future, but another concussion could cause long term problems for his son.  So, I stood by my recommendation, for which his mother “thanked me”.  His team played the game and of course they lost. I felt terribly for their loss, but at the same time, knew that medically this was the appropriate decision. So many times, we as parents get so “wrapped up” in our children’s lives, whether it be in sports, academics or even having the “best” birthday party, that we lose sight of the “big picture”.  I see the” big picture” as trying to make the best decisions for our children, given the best information that we have to help make that decision. Many of those decisions may not be easy, but we as parents know they are right.  Whether that is keeping your child from playing a soccer game after suffering a concussion, or taking away a teen’s cell phone and computer privileges after they have been drinking under age.  There are so many of these difficult decisions and we all hope to make them correctly. This patients family did, and I am proud of them! That's your daily dose for today.  We'll chat again tomorrow! Send your question or comment to Dr. Sue!

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Concussions

Your Child

Study: More and Younger Children Suffering From Concussion

2:00

In order to develop statistics on how many U.S. children and teens are being diagnosed with concussion, the Centers for Disease Control and Prevention (CDC) analyzes emergency room data from around the country.

But, a new study finds that children’s concussions may be vastly underreported because family pediatricians, not ER doctors, are doing the examinations.

In the study, published today in the Journal of the American Medical Association Pediatrics, researchers from Children's Hospital of Philadelphia (CHOP) and the CDC used CHOP's regional pediatric network to figure out when and where children were diagnosed with a concussion.

They found approximately 82 percent had their first concussion visit at a primary care site like a pediatrician's office, 12 percent were diagnosed in an emergency department, 5 percent were diagnosed from a specialist, such as a sports medicine doctor or neurologist, and 1 percent were directly admitted to the hospital.

The authors noted that the findings indicate that many more children have suffered a concussion than recent stats suggest.

In another surprising turn, researchers found that one-third of those injured were under the age of 12.  Many reports have been focused on teen athletes instead of younger children.

"We learned two really important things about pediatric concussion healthcare practices," Kristy Arbogast, lead author and Co-Scientific Director of CHOP's Center for Injury Research and Prevention, said in a statement today. "First, four in five of this diverse group of children were diagnosed at a primary care practice -- not the emergency department. Second, one-third were under age 12, and therefore represent an important part of the concussion population that is missed by existing surveillance systems that focus on high school athletes."

Alex Diamond, a pediatric sports medicine specialist at Vanderbilt University Medical Center and director of the injury prevention program, told ABC News that these findings are important to help health officials understand how prevalent concussions really are. Diamond was not involved in the study.

Pediatricians are a good choice for seeking advice and diagnosis on concussions because they know the history of the child, Diamond said.

"That’s why it’s great for a pediatrician to deal with this," Diamond said. "They know the kid at baseline and they know the family."

The findings may have far-reaching implications for what we know about the number of concussions in the U.S., the authors said, noting that this study suggests that the condition is extremely underreported if the vast majority of concussions are diagnosed outside the emergency department.

"We need surveillance that better captures concussions that occur in children and adolescents," Dr. Debra Houry, director of CDC's National Center for Injury Prevention and Control, said in a statement today. "Better estimates of the number, causes, and outcomes of concussion will allow us to more effectively prevent and treat them, which is a priority area for CDC's Injury Center."

Concussions often happen without a loss of consciousness and can have long-term effects.

In fact, a brief loss of consciousness or "blacking out" doesn't mean a concussion is any more or less serious than one where a child didn't black out.

If your child might have had a concussion, go to the emergency room or see your pediatrician if he or she has any of these symptoms:

•       Loss of consciousness

•       Severe headache, including a headache that gets worse

•       Blurred vision

•       Trouble walking

•       Confusion and saying things that don't make sense

•       Slurred speech

•       Unresponsiveness (you're unable to wake your child)

•       Ringing in the ears

•       Nausea

•       Vomiting

Some symptoms of concussions may be immediate or delayed in onset by hours or days after injury, such as:

•       Concentration and memory complaints

•       Irritability and other personality changes

•       Sensitivity to light and noise

•       Sleep disturbances

•       Psychological adjustment problems and depression

•       Disorders of taste and smell

Symptoms in infants and toddlers may be more difficult to recognize because they cannot express how they feel. Nonverbal clues of a concussion might include:

•       Appearing dazed

•       Listlessness and tiring easily

•       Irritability and crankiness

•       Loss of balance and unsteady walking

•       Crying excessively

•       Change in eating or sleeping patterns

•       Lack of interest in favorite toys

Experts recommend that parents take their child in for an evaluation if their child receives more than a light bump on the head.

Story sources: Gillian Mohney, http://abcnews.go.com/Health/concussions-children-vastly-underreported-study-finds/story?id=39506549

http://www.mayoclinic.org/diseases-conditions/concussion/basics/symptoms/con-20019272

Your Teen

Concussions: Boys and Girls May Have Different Symptoms

1.45

The findings suggest that boys are more likely to report amnesia and confusion/disorientation, whereas girls tend to report drowsiness and greater sensitivity to noise more often.A new study of high school athletes, finds that boys and girls who suffer concussions, may differ in their symptoms. The findings suggest that boys are more likely to report amnesia and confusion/disorientation, whereas girls tend to report drowsiness and greater sensitivity to noise more often. "The take-home message is that coaches, parents, athletic trainers, and physicians must be observant for all signs and symptoms of concussion, and should recognize that young male and female athletes may present with different symptoms," said R. Dawn Comstock, an author of the study and an associate professor of pediatrics at the Ohio State University College of Medicine in Columbus. More than 60,000 brain injuries occur among high school athletes every year, according to the U.S. Centers for Disease Control and Prevention. Although more males than females participate in sports, female athletes are more likely to suffer sports-related concussions, the researchers note. For instance, girls who play high school soccer suffer almost 40 percent more concussions than their male counterparts, according to NATA. The findings suggest that girls who suffer concussions might sometimes go undiagnosed since symptoms such as drowsiness or sensitivity to noise "may be overlooked on sideline assessments or they may be attributed to other conditions," Comstock said. For the study, Comstock and her co-authors at the University of Virginia, Charlottesville, and the University of California, Santa Barbara, examined data from an Internet-based surveillance system for high school sports-related injuries. The researchers looked at concussions involved in interscholastic sports practice or competition in nine sports (boys' football, soccer, basketball, wrestling and baseball and girls' soccer, volleyball, basketball and softball) during the 2005-2006 and 2006-2007 school years at a representative sample of 100 high schools. During that time, 812 concussions (610 in boys and 202 in girls) were reported. During the first year of the study, the surveillance system included only the primary concussion symptom for each athlete. In the second year, high school athletic trainers were able to record all the symptoms reported by the concussed athlete. In both years, headache was the most commonly reported symptom and no difference was noted between the sexes. However, in year one, 13 percent of the males reported confusion/disorientation as their primary symptom versus 6 percent of the girls. Also in the first year, amnesia was the primary symptom of 9 percent of the males but only 3 percent of the females. In the second year, amnesia and confusion/disorientation continued to be more common among males than females. In addition, 31 percent of the concussed females complained of drowsiness versus 20 percent of the males, and 14 percent of the females said they were sensitive to noise, compared with just 5 percent of the males. Concussion researcher Gerard A. Gioia, chief of pediatric neuropsychology at Children's National Medical Center in Washington, D.C., called the findings "relatively subtle" and "at best hypothesis-generating, meaning they are suggestive but in no way conclusive." Gioia said one of the study's limitations is that the reporting system didn't explain about how the injuries occurred. "The presence of increased amnesia and confusion, two early injury characteristics, in the males suggests that the injuries between the males and females may have been different," he said. Future studies will likely address this theory, said Comstock, now that the surveillance system has been expanded to include much more detailed information. Preliminary data suggest, for instance, that football players tend to get hit on the front of the head, while girls who play soccer or basketball often suffer a blow to the side of the head, she said. The findings will also be published in the January issue of the Journal of Athletic Training.

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