How to Mismanage a Child’s Concussion

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

Lots of myths and misinformation exist about how parents and coaches can supervise the recovery of a child’s concussion. Some of the most common ones stem from advice that was given years ago. But better understanding of brain injuries and new imaging technology has changed how concussions are treated. Here’s what NOT to do when managing your child’s injury.

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1  — Waking Every Hour or Two
Decades ago, physicians and clinicians encouraged parents to wake up their concussed children frequently to monitor their mental status. However, with modern imaging and clinical evaluations, patients who have been cleared by a concussion specialist can sleep soundly. In fact, remaining asleep 12, 15 or even 20 hours following a head injury is actually helpful, restful, and promotes faster recovery.

2 — Return to the Game Too Soon
Most concussion laws in every state have a provision in which a child is removed from play when a concussion is suspected and can only be cleared to return by a concussion specialist. Unfortunately, clinicians will periodically encounter an overly ambitious parent wanting to return his or her child to play prior to making a full recovery from the concussion. Depending on the timing, this can be exceedingly dangerous. If it is too soon, the child may be in danger of secondary impact syndrome, which can be fatal.

3 — Keep Away from Friends and Electronic Devices
Socialization is an important part of adolescent development. Keeping a child completely isolated from friends and electronic devices can lead to a sense of isolation, and in some cases, even depression. Clinicians and parents need to be mindful of balancing remediation with a young person’s sensitive self-esteem.

4 — Promote Completely Inactivity and Darkened Rooms
Although some rest is thought to be useful from 48 to 72 hours after the head injury, extensive rest and inactivity in a dark room is actually thought to do more harm than good. The brain can actually have more difficulty to returning to normal activity following an extensive period of inactivity.

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Why Concussion Risks are Higher for Women

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director
and Ann-Marie Sedor, HeadFirst Concussion Care Marketing

A number of research articles suggest that women are more susceptible to mild Traumatic Brain Injury. In fact, female college athletes have a higher rate of concussion compared to males when playing soccer (2.1 x greater risk), softball versus baseball (up to 3.2 x greater risk), and basketball (up to 1.7 x greater risk). So, why the difference? Research and anecdotal evidence has turned up three possible reasons: cultural differences; hormonal differences, or physiological differences.

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Canada forward Christine Sinclair (right) and USA midfielder Carli Lloyd head the ball during the 2016 CONCACAF women’s Olympic soccer tournament at BBVA Compass Stadium in Huston, Texas, on February 21. Soccer is also among those sports programs that produce a large share of concussions for female athletes. — Reuters

Some experts have said part of the reason for increased concussions in females may be due to the reporting rate — that women are more likely than men to notify a coach they are injured, whether due to a head injury or other concern. Cultural differences indeed indicate a reluctance among males to report any injuries for fear of being removed from play. However, because of the very nature of concussion being a clinical diagnosis that usually depends on self reporting, it is hard to say that the incidence differences between the genders is due to honesty.

Other research suggests that hormones including estrogen, oxytocin, progesterone, and testosterone, affect recovery times from concussion. Of course, men and women have vastly differing levels of these hormones. One published study from the University of Rochester (NY) has also shown that menstrual cycles play a part in healing from head trauma. The research showed that women in child-bearing years experience greater cognitive decline, delayed reaction times, extended periods of depression, more headaches, and longer hospital stays and return-to-work plans compared to men following head injury.

Other articles suggest that longer and weaker necks of female athletes influence the potential for greater cervical injury and flexibility of the cervical ligaments. During a 2013 Youth Sports Safety Summit presentation, recent findings from athletic trainers showed neck strength and rigidity could help lower the chance of concussion. For every one pound increase in neck strength, odds of brain injury fell by 5 percent. Consequently, some the nation’s foremost authorities on concussion suggest female athletes participate in daily neck strengthening exercises.

Other research suggest that there are different neuronal connections between the hemispheres and significant lobes within the cerebral cortex for men and women potentially influencing recovery time. A recent Georgetown University Medical Center study showed that mice with a single head injury temporarily lose 10 to 15 percent of the neuronal connections in their brains, which can be repaired when at least a week of rest is provided. The fact that male and female brains are “wired” differently could account for a higher incidence of and/or a longer healing period after brain injury in women.

Realistically, interplay of all of these factors could potentially influence the differences in concussions between the number of concussions of female athletes and their recovery.

Significant Head Trauma Can Occur with Repeated Hits, Not Just Concussions

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

CTE’s connection to football has been in the news for five years now, with a debate centered around whether the number of concussions will affect long-term health and well-being of those playing the sport. Likewise, I’m constantly asked by patients and parents what the future effect of this or future concussions will be on their health. A recent study released by researchers at the Boston University School of Medicine (such as Dr. Robert Cantu, Dr. Ann McKee, Chris Nowinski and others) will probably give moms and dads across America a moment of pause before starting a collision sport like football or hockey.

An answer may lie in a concept developed by these researchers called the Cumulative Head Impact Index (CHII). They found individuals who had more hits to their heads—regardless of whether they had a concussion or not, were significantly (i.e., not even close…a large statistic margin) more likely to experience later-life cognitive problems, apathy and depression. The caution here is that the sample size was only 93 individuals and the exposure was only to football.

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A football helmet’s health warning sticker is pictured between a U.S. flag and the number 55, in memory of former NFL player Junior Seau; new research suggests that the accumulation of subconcussive hits may have more significant long-term effects than concussions. (© Mike Blake / Reuters/REUTERS)

The next step is for medical providers and concussion specialists to help families begin to connect the dots throughout the developmental hurdles of a child’s life. For example, the health outcomes for two 7th grade beginning hockey players if they have a different history. One student may have fallen off a changing table as an infant and suffered a skull fracture, have been in a motor vehicle accident, and have fallen multiple times during winter sports, while the other 7th grader may not have suffered any head injuries or significant head trauma. Baseline neurocognitive testing like the ImPACT® test might look different on these two young students, and the outcome and recovery time of any current injuries sustained by each of them could be considerably different.

I’ve often said that kids can’t live in a bubble as much as parents are sometimes inclined to want to wrap their kids in bubble wrap. Young people—really, people of all ages—are going to be in car accidents, bike accidents, and slip and fall just going through life. Parents need to make their own unique, informed decision about how much additional risk of physical injury to which they want to expose their child, given his or her medical history and athletic abilities.

The Connection Between Concussions and Suicide

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

The topic of mild traumatic brain injury and/or concussion has been in the news for several years. The release of a major motion picture, a concussion sustained by a professional sports star, or the passage of a law tends to rekindle interest in the topic. Recently, another issue was linked to concussion — the concern of suicide. But, I am optimistic. Why? By nature, I’m an optimist, but I’m also hopeful that parents, community leaders and politicians will pay attention to the epidemic of suicide in our country.

When I worked in the U.S. Navy, one of my careers was serving as their Suicide Prevention Program Coordinator. Every death by suicide crossed my desk. The number of Marines and Sailors who attempted and completed suicide staggered me.

In our country, the number of people — servicemembers or civilian — who die by suicide is almost too much to comprehend. Compared to 16,000 homicides each year in the U.S., the number of suicides is nearly double that at almost 32,000 a year, most due to untreated depression of some form.

Let’s put those numbers in another perspective: In the last decade of our troops fighting in Afghanistan and Iraq, just over 7,000 Americans have made the ultimate sacrifice and almost 50,000 have been wounded. During that same time, more than 300,000 have died by suicide and more than 50,000 have been children between the ages of 14 and 24. The number of suicide attempts is in the millions.

Researchers are also finding out that some of the consequences of concussion are linked to depression and suicide. Untreated brain injuries can lead to devastating consequences.

My optimism lies in the hope that coaches, parents, athletes, and community leaders understand that the physiology of a concussion caused by a blow to the head or body prompts the neurons to function ineffectively due to a disruption of their normal chemical process.

I’m optimistic that these same parents, coaches, athletes, and community leaders will make the connection that the neurological process of a concussion is to depression. That these neurons which govern our emotions and self-esteem for a variety of different reasons — the death of a loved one, loss of a job, bankruptcy, medical conditions — can lead to a disruption of the neurons and cause depression leading to suicide.

I’m optimistic that the people who form every individual’s support system, from parents and teachers to friends and fellow athletes, will ACT if something seems amiss:
A — ask an individual if he or she is thinking about suicide
C — let him or her know you care about them
T — get the individual to treatment with someone who specializes in suicide evaluations: a counselor, pastor or chaplain, family doctor or pediatrician, psychologist, or psychiatrist or local emergency room

Concussion-Suicide-Risk-March-2016-900x900I’m optimistic that people will realize that depression can be considered the “common cold” of psychiatric conditions and has a variety of effective treatment options.

I’m optimistic that people will pass on the suicide prevention hotline number and website to those in crisis: 1-800-273-TALK and www.suicidepreventionlifeline.org.

And finally, I’m optimistic that people will pass this blog and information onto at least FIVE other people and in doing so, might just save a life.

How Much “Strict Brain Rest” is Needed After a Concussion?

by Majid Fotuhi, M.D., Ph.D.
Founder & Chief Medical Officer, NeurExpand Brain Center
Guest Contributor

Guidelines by the American Academy of Neurology, American Academy of Pediatrics, and many sport organizations emphasize the importance of brain rest after a mild TBI. Now, a new study published in the January 5 issue of Pediatrics questions the validity of recommending 5 days of strict rest to all children who suffer a concussion.

Authors examined the difference between the outcomes of two groups of children (average age of 13-14 years old) who presented within 24 hours of a head injury to an emergency room. Half were told to rest for as long as needed, usually for 1-2 days, followed by stepwise return to the usual level of activity. The other half was told to rest for 5 days, without engaging in any school or work engagements, followed by stepwise return to activity. Participants had neurocognitive (ImPACT) and balance assessments at baseline and at their follow-up visits at 3 and 10 days. They also kept a diary of their activity level and how they felt.

In both groups, 60% of participants reported resolution of their symptoms. However, half of the “strict rest group” took 3 additional days to reach a full recovery. This strict rest group also tended to have a larger amount of emotional issues, as they were kept away from school and social settings. Children in the strict rest group who had headaches at the onset of their concussion tended to have lingering symptoms for a longer period of time than the control group. The one exception to better outcomes in the control group was for children who had immediate loss of consciousness or amnesia at the time of their injury. These children seemed to benefit from 5 days of strict brain rest.

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In general, it appears that not all children who experience a mild TBI should receive a prescription for strict 5-day brain rest. There may be benefits in treating each patient individually, depending on their initial symptoms, level of cognitive function, and severity of concussion. Some may need no rest, some may need 1-2 days of rest, and yet others may need 5 or more days of avoiding demanding brain stimulation.  More studies are needed before the current guidelines can change. The one recommendation that is gaining more support in recent years is to have patients engage in exercise early in their post-concussive period.  Increasing physical activity tends to do wonders for rehabilitation of patients who suffer from a stroke (which is a vascular brain injury) and it may be just as beneficial for kids or adults who have had a traumatic brain injury.

For now, if you have had a brain injury, please be sure to see your doctor or a sports medicine specialist who is familiar with concussion management issues. Your brain is a precious organ and it’s important to work with experts in the field  on controlling your symptoms and finding the best resolution for full recovery. Otherwise you may end up having lingering post-concussive symptoms for months, years, or decades.

SOURCE: Anderson, P. (2015, January 7). Strict Rest After Concussion Offers No Additional Benefit.

March is Brain Injury Awareness Month

by Tony Doran, Psy.D.
HeadFirst Concussion Care Program Director

In the past several years, few medical problems have generated as much public interest as sports-related concussions. Coaches, parents, and players are increasingly aware that a concussion involves an injury to the brain and that an athlete suspected of having a concussion should be removed from play and evaluated by a licensed health care professional. I’d like to share a little bit about myself and how I became interested in the area of mild traumatic brain injury (mTBI).

My name is Dr. Tony Doran. I was a clinical psychologist for the Navy for the past 20 years. The Navy sent me to Harvard Medical School and I specialized in pediatric neuropsychology. Over the course of my career, I have worked in a variety of diverse positions at Portsmouth Naval Hospital, Iwakuni Medical Clinic Japan, and the United States Naval Academy. I have treated kids and adults with everything from adjustment reactions and craniosynostosis to mTBI and PTSD (post-traumatic stress disorder).

As my time in the military was winding down, I began to explore where my next adventure would take me and I naturally gravitated to conducting evaluations for Special Forces Units throughout the United States. After more than 10 years of war, I have treated and evaluated hundreds of service men and women who were dealing with the wounds of war coping with PTSD and mTBI. As the war was coming to a close, I began to look at what other avenues I could explore. My contracting position of evaluating Special Forces Units involved a lot of travel away from my family, which initially was exciting and interesting, but after 3 years was beginning to wear on myself and my family. So I began to look for a permanent position.

Having been a consultant, I had performed some services for a new company in the area of concussion care called HeadFirst. HeadFirst was evaluating and treating hundreds of kids with mTBI and a substantial percentage of these kids had some special needs – autism, learning disabilities, attention problems or other psychological problem. My experience and training in mTBI and childhood disorders would help me treat and evaluate these children. HeadFirst was looking for someone to evaluate the enormous amount of data they were beginning to collect and also help them branch off and start new research projects. My years of data analysis and research in the Navy would assist me in this area. Several weeks later, I was hired as the Program Director of HeadFirst. I look forward to educating parents, children and coaches in the area about mTBI, treating children and teens with mTBI, and conducting research in the area of mTBI.

Dr Doran-Bug-Sm

I was at a meeting the other night with several health care providers and asked them to please share a story about what a concussed child or family member had asked them about after brain rest had been explained to them. As we went around the room, kids and family members asked about playing the drums, going snowboarding, playing football with dad in the yard, sleigh riding, mountain climbing, just shooting baskets or just swinging in a batting cage. Answers like theirs beg the question: Are our kids, families, and coaches getting the message about the seriousness of mTBI?

Pardon the Navy analogy, but sometimes big ships take a while to turn. I am encouraged when I hear teens make comments like “Hey, that kid has to stay out of competition for at least 7 to 10 days” after witnessing a concussion and a parent discussing with a child that she might need to permanently switch to a different sport – like track or swimming – after her fourth concussion in soccer. However, when I still get questions like “Can I go ride my go cart?” after explaining brain rest, I am reminded that we, as providers, educators and researchers, have more work to do.

If you are interested in joining the concussion discussion, please visit this blog as we will be having different providers, coaches, parents and recovering patients contribute. Also please see our website for community events.

The Brain Injury Association of Maryland is having their annual conference March 20th-21st – please see their website to find out more and I hope to see you there.

The “Mild” Concussion Misnomer

On Sunday, Washington Redskins quarterback, Robert Griffin, III was knocked out. According to his coach, Mike Shanahan, he received a mild concussion. When asked about RGIII, Shanahan said the following – “He wasn’t sure what quarter it was in the third quarter. So at that time, when he wasn’t really sure what the score was, what the quarter was, we knew he had a mild concussion — at least according to the doctors,”

 

This leads us to the question – is it possible to get a “mild” concussion?

And the resounding answer is NO!

According to the CDC a concussion is a brain injury, and ALL are serious.

When talking about concussions, the word mild can be used to describe the symptoms. Symptoms can be mild to severe.  You will also hear the word mild to describe the type of brain injury. A concussion is a mild traumatic brain injury, but do not confuse this with having a “mild” concussion. Again all concussions are serious and need to be treated that way.