Reflections and Updates from Spring and Summer Concussion Conferences
July 14, 2014
I have had both the pleasure and good fortune the first half of this year to attend four symposiums and conferences on the diagnoses and management of mild Traumatic Brain Injury (mTBI or concussion). I had the opportunity to listen, learn and interact with the premier researchers and leaders in this exploding area of science, from the perspectives of Sports Medicine Physicians, PhD. level Athletic Trainers in research, Sports Neuropsychologists and Neurologists themselves. The level of enthusiasm is very encouraging, and the quality of the research is proof of their dedication. While what we really know (have definitive proof) concerning the best way to prevent, diagnose and treat these injuries is incomplete in many areas, that is changing rapidly. The amount we definitively know about concussion and the tools to prevent, diagnose and manage them will only continue to accelerate exponentially. I wanted to take a few minutes to share some highlights and updates regarding prevention, improving technologies, treatment and long-term outcomes–all relevant to parental concerns, like my own.
I have written recently about the role of helmets in preventing injury. The truisms are that helmets primarily serve to prevent catastrophic injuries such as skull fractures and associated brain bleeds. It remains true that a properly fitted (read snug) helmet worn properly is the most important determinant in safety. But as I briefly mentioned before, Steve Rowson, PhD and Stefan Duma, M.D. have been working at Virginia tech to come up with a rating system called the STAR rating system which is included in the Virginia Tech Ratings–higher the stars the better the ratings. To back up a little bit, an association named National Operating Committee on Standards for Athletic Equipment (NOCSAE) that was formed in 1969 has been the body which grades the safety of athletic equipment including helmets. For various reasons they have come under great criticism for failing to adapt as research has progressed. Drs. Rowson and Duma take the intuitive position that all helmets are not equal in protecting from concussion and correctly admit that no helmet ever will, that was not the intent of their initial design. The reasoning is that some helmets distribute the force more evenly in a hit and that some helmet liners can therefore reduce concussion lowering head acceleration. Their ratings are based on both lab and on the field evidence that correlate, with 5 star helmets offering the greatest protection in adults, although the intimation was made that these ratings may be valid for larger adolescents at or above the age 15. Until there is a published formal endorsement, take that with a large grain of salt, although I believe there is merit here. Please have a look at the link. In regards to Pop Warner age groups, the main determinants are rule changes, specifically those that limit contact in practice and eliminate high risk drills. In the first year after this was implemented there was over a 50% drop in head impact exposure.
Some brief words on accelerometers. There are two major forces that are thought to cause concussion, linear and rotational acceleration with the latter being the most detrimental force (for those students of the game it seems obvious). Some of those sensors are mounted inside the helmet, some on the neck and some in the mouthguard. The thought is that if an athlete receives a blow above a certain level he can be pulled from play and examined. There are a multitude of devices coming out commercially, some marketed to Sports Medicine professionals and some directly to parents which you may have heard about. There are still problems with the logistics, accuracy and determining the correct cutoffs of when to take action. Sometimes they are obvious, most of the time not quite. We are evaluating two separate sideline concussion management systems that incorporate critical tools we use, both of which will include accelerometers measuring linear and rotational forces very soon. The logistics of implementation are considerable, and the technology is still young. Personally as a parent I would not advise buying one of these devices unless your child is in a situation where no Certified Athletic Trainers are in attendance. Even then I would have second thoughts until the devices are validated by different sources and the interpretation of the numbers and their cutoffs are better studied. There is an issue of subconcussions that we will discuss at a later date.
Let’s switch gears to treatment. It has been finally recognized (seemed like a long battle to me) that early cognitive rest, or cocoon therapy has the highest yield for rapid improvement, at least for the first few days after concussion. Sleep is paramount in recovery, but much more important at night. How long should we restrict technology, television, bright light, loud places and the like? That is where the art of medicine comes into play, for now. Again, no two individuals are the same, and no two concussions are identical. Generally however, on or after the third day of stimulation avoidance, depending on the severity of the concussion, mild exercise, whether it be walking or stationary bike at low intensity, is thought to help in the healing process (participating in activities where your head might get hit is NOT!). Then we slowly re-introduce things like reading out of a paper pen book, watching television as tolerated. Once those things are tolerated with few to no symptoms, it is time to try school as symptoms tolerate with certain accommodations, BOTH scheduled and as needed. For example, late arrival might be appropriate and paper and pen assignments are encouraged. Once the athlete is fully functional, they may try the Return to Play protocol administered by our athletic trainers, physical therapist and at times coaches. In summary, we take each case by case based on historical factors and examination and try to get the student back to normal as soon as it is tolerable–sooner than we have before.
Some good news to finish. About to 85%-90% of adolescents still improve within 7-10 days! Close to 20% are symptom free after 24 hours. Less than 3% will have a prolonged concussion, greater than three weeks or a month. Some risk factors are known (ADHD, treatment for psychiatric conditions, learning disability, migraines or family history of migraines, prior concussions that were severe), but genetic and serum biomarkers indicating increased vulnerability will be on the market not too long from now. While there is mixed evidence on the long-term effects of concussions in adolescents, there is no proof that, when properly recovered, diseases such as the much discussed Chronic Traumatic Encephalopathy(CTE) in the news are likely to result. In fact, in studies comparing high school football players and band members 50 years out, there was no discernible neurological differences. With rule changes, safer playing techniques, identification of the early signs of concussions, taking risk factors (including genetics) into account, more awareness of the condition and improving technology… the sports we love and contribute to our health will not go way, even if the rules have to change some.