The American Academy of Pediatrics just released an update on Sport-Related Concussions in Children and Adolescents. This 24-page report highlights the major developments in new concussion knowledge and treatment since the first report, which was published in 2010.
To follow are the points that I find to be of particular interest. Some the conclusions and actionable recommendations may be contrary to what is being disseminated by various bloggers and vendors of products related to concussions. But always remember that true science can be a very slow process and future studies may ultimately prove contrary results. If these topics are of interest, you should read the entire article for more information.
Concussions: Mechanical vs Chemical/Cellular Injury
There is no universally-accepted definition of a concussion and there are a wide range of symptoms which require individual management.
After a biomechanical injury to the brain due to either direct impact or whiplash effect, a cascade of chemical changes occur resulting in injury on a cellular level. Some of the medical terms for these are potassium efflux from neurons, increase in extracellular glutamate, upregulation of sodium-potassium ion pumps, depletion of intracellular injury reserves, and increased use of adenosine triphosphate and hyperglycolysis. All of these biochemical reactions result in decreased blood flow and increased energy demand which leads to an energy crisis.
In other words, concussions are a lot more complicated than just a bump to the head, making future research and studies necessary.
Rest After Concussions
After a concussion, an immediate reduction in physical and mental activity can be beneficial to recovery. However, prolonged restrictions of physical activities and delayed return to school can have negative effects on recovery and symptoms. A graduated return-to-play protocol should be followed under the supervision of a healthcare professional.
Reporting of Concussions Over the Past Decade
Studies indicate that the reporting of youth concussions has increased dramatically over the last decade with increases ranging from 57% to 200%. This is likely caused by the increased overall awareness of coaches, participants, and parents due to media exposure and education initiatives.
Concussions in Girls vs Boys
Female athletes are more likely to report symptoms to an authority figure than male athletes, despite both having the same knowledge.
Studies indicate that concussion rates from highest to lowest for boys are as follows: American tackle football, lacrosse, ice hockey, and wrestling. For girls: soccer, lacrosse, field hockey, and basketball.
Girls have higher concussion rates than boys in soccer and basketball.
The reasons that girls seem to be more susceptible are not entirely clear, but it has been suggested that it is due to weaker neck musculature and estrogen.
In school sports, for boys and girls combined, the following have the highest concussion rates: middle school tackle football, girls soccer, cheerleading, and girls basketball.
A study of youth tackle football for ages 8 to 12 indicates that the concussion rates are higher than in high school athletes and that 11 to 12 year olds have a nearly 2.5 increased risk as compared to 8 to 10 year olds.
Concussion incidence is higher in competition than in practice for males and females across nearly all sports.
Most Frequent Signs and Symptoms
Headache 86% to 96%
Dizziness 65% to 75%
Difficulty Concentrating 48% to 61%
Confusion 40% to 46%
Problems to Watch Out For in Post-concussion Diagnostic Tests
The most frequent sideline test used by athletic trainers is the Sport Concussion Assessment Tool (SCAT) and is available in following forms: Child SCAT 5 (ages 5 to 12) and SCAT 5 (ages 13+). These tests, which only take about 10 minutes to perform, are being constantly updated. They consist of observable signs of concussion, symptoms assessment, memory questions, neurological assessment, and balance assessment.
Symptoms can mimic pre-existing problems such as migraine, headache disorders, learning disorders, ADHD, mental health conditions, and sleep disorders. As a result, the examiner should be informed of any such condition.
Some sideline diagnostic assessment tools and checklists are not appropriate for children ages 5 to 12. Younger athletes perform worse on questions such as naming months or numbers in reverse. Variations are available for younger children such as the Child SCAT 5..
Tests that measure visual deficits, such as the King-Devick Test, show promise but not enough evidence from studies yet to recommend their inclusion in the SCAT.
While healthcare professionals find sideline assessment tests to be helpful, they are not to be used in isolation in diagnosing a concussion. Not enough studies exist at this time to recommend widespread use in children. Also, the value of sideline tests is minimized without a baseline test for comparison. See HitCheck for an example of an affordable sideline assessment app.
Are CAT Scans and MRIs Necessary? Which One Is Superior?
CAT scans and MRIs are critical when a severe intracranial injury or structural lesion (skull fracture or hemorrhage) is suspected, but they are not effective in diagnosing a concussion. Despite this, the use of neuroimaging increased 36% between 2006 and 2011.
Recent literature indicates that it is highly unlikely that significant intracranial hemorrhaging occurs after six hours without a deterioration in the level of consciousness. As a result, prescribing a CT without any deterioration of consciousness after six hours is unlikely to be helpful.
When neuroimaging is necessary, CT’s are more cost effective and can usually be arranged more quickly. However, children’s exposure to radiation may increase the risk of certain cancers over the long term. After the emergency period is over, MRIs are superior to CTs in detection of cerebral contusion, petechial hemorrhage, and white-matter injury.
Baseline Neurocognitive Testing
Studies conducted independently by developers of paper and online testing platforms have questioned the reliability of baseline tests from year to year. It is important for the reviewer who compares baseline to post- injury tests to understand modifiers that could alter results, such as depression, lack of sleep, failure to take ADHD medication, and athletes with musculoskeletal injuries.
The best environment for baseline and post-injury testing is a quiet, distraction-free environment, which can be very difficult to achieve for most schools and organizations.
Concerns about athlete “sandbagging” and intentionally under-performing on baseline tests are exaggerated as this can be detected.
Neurocognitive tests should not be used as the sole determining factor in return-to-play decisions.
Retirement After Multiple Concussions
The decision to retire an athlete after multiple concussions should not be tied to any specific number of concussions.
An athlete who has suffered multiple concussions should be referred to a specialist with expertise in this area for guidance.
Prevention of Concussions: What Can Be Proven By Studies
- Mouth guards: After an initial 1954 study suggesting a connection between mouth guards and reduction of concussions, several larger studies refuted this assertion. Evidence of an advantage of custom mouth guards over non-custom remains inconclusive.
- Helmets: Helmets were designed to reduce severe injuries such as skull fractures, subdural hematomas, and brainstem contusion or hemorrhage. The goal of reduction of concussions has not proven to be productive. Several studies show no difference between several brands and models of helmets, both new and refurbished, in terms of severity of symptoms, frequency, and recovery time. Helmet improvements are not likely to ever be the solution to the concussion problem.
- Aftermarket Helmet Attachments: No study has ever shown that aftermarket helmet attachments such as pads, shock absorbers, and sensors prevent or reduce the severity of concussions. The use of sensors to clinically diagnose or assess concussions cannot be supported at this time and do not have a role in decision making. See our article “Add-on Helmet Products.”
- Other Headgear: Soccer headgear has not proven beneficial in the reduction of head-to-head or head-to-ball impact. Such headgear may actually increase the incidence of injury by encouraging more aggressive play.
- Education: Education and awareness of concussions has proven effective in diagnosing, treating, and making return-to-play decisions. This finding is consistent with Sadler Sports Insurance injury data on concussion rates in youth baseball and football prior to 2012 and after 2012.
- Biomarkers: Biomarkers have been investigated in playing a role in concussion evaluation. These include predisposition factors, delayed recovery, and increased catastrophic risk. These investigations are preliminary and none have advanced to use in a clinical setting.
- Supplements: Numerous supplements have been investigated as to playing a role in preventing or in speeding up the recovery time from concussions. There are currently no studies in humans to support a benefit from supplements.
- Neck Strengthening: Strengthening the cervical muscles and activating those muscles prior to impact has been found to reduce forces from head impact. Poor neck strength has been shown to correlate with the incidence of concussions. One study showed that each additional pound of neck strength resulted in a 5% reduction in concussions.
- Rule Changes: Rule changes and enforcement of rules by officials may help to reduce the likelihood of concussions. Recent initiatives in youth sports look promising. These include elimination of checking in ice hockey and heading soccer in younger age groups, and reducing contact in football practice.
I hope you enjoyed my summary of this very informative article. At Sadler Sport Insurance, we have an excellent risk management library on the topic of concussion and brain injury risk management that you should check out.