Tuesday, December 22, 2015

Concussion anxiety

Earlier this year, Jeanette, a 17-year-old high school senior, came to my office after her third “concussion” in three years.  She had been bumped in the head during volleyball practice, but not knocked out, and then developed headaches that went away after two weeks. A nurse practitioner in her pediatrician’s office benched her for the season. But Jeanette wanted to play; it was her senior year, after all.

I have been a pediatric neurologist for 40 years, and over the past five years, I have evaluated dozens of children for potential neurological complications of concussion. Most, like Jeanette, had no serious problems. Obviously, concussions are a real concern. But what’s also worrisome is that excessive fear of concussions may discourage parents and medical professionals from letting kids play healthy team sports...
Of course, severe head trauma certainly can lead to permanent brain damage. Consider the history of boxing. In 1928 a pathologist identified brain abnormalities in “punch drunk” boxers, who had developed neurological problems as they aged. The severity of their illness correlated, in part, with the number and intensity of blows over their careers.
Dr. Bennet Omalu (see Ridicule and rejection 11/23/15), a neuropathologist, and his colleagues have identified similar brain abnormalities, known as chronic traumatic encephalopathy, in autopsies of professional football players who had played for years. The disease has also been identified in elite soccer and hockey players, as well as combat veterans exposed to roadside bombs.
The real issue is that data about brain damage in adult professional athletes can’t be applied to children playing these sports over a shorter period of time. As far as I know, detailed post-mortem brain examinations looking for C.T.E. have been conducted only on military veterans, adult athletes who played for years and others with known neurological problems.
To make more informed decisions about whether children should play these sports, we would need to know whether C.T.E. can be found in adults who played contact sports as kids but for shorter periods of time. But no well-designed study has yet addressed what severity or recurrence of head injury is needed to cause C.T.E...
In 2013, the American Academy of Neurology broadened its definition to include a variety of possible symptoms caused by mild head trauma, including headaches, amnesia and sensitivity to light and sound — but not necessarily loss of consciousness. Unfortunately, these symptoms are not specific, and have been reported in high school athletes with no recent concussions.
This doesn’t mean we shouldn’t be smarter about sports-related head injuries. No one doubts that a child should immediately be removed from a game if she experiences any neurological symptoms after an impact. And it’s common sense to require her to sit out the remainder of the game.
My advice has been to require a patient to stay symptom free for a week before she can return to contact-free practice. If the patient is still asymptomatic after two weeks, she can return to normal play. But if an athlete experiences two concussions in a single season, she must sit out the remainder of the season and possibly return the next year. (Unfortunately, this hasn’t been the standard of care for many college and professional athletes.)
There is a way to exercise such caution without exaggerating the scope of concussions. The American Academy of Pediatrics and the American Academy of Neurology should redefine mild head trauma that produces only headaches as a “noncussion.” The definition should emphasize that symptoms go away within seven to 10 days, and children should withdraw from full play for at least two weeks. If the athlete, family and coaches all agree that the child has fully recovered, it would not be necessary to consult a pediatrician or neurologist.
These recommendations should apply to elementary and middle school students whose parents and doctors have barred them from low-risk sports like soccer, baseball, basketball, volleyball and cheerleading over concerns of recurrent brain damage. While there may be outliers whose brains are vulnerable to minor impact because of subtle variations in brain anatomy, it would be nearly impossible to identify them in advance.
In the meantime, we have a disconnect. At the elite professional level, men and women who suffer obvious brain injury are being left on the field. Meanwhile, too many teenagers who face little chance of long-term brain injury are being kept from playing in healthy organized sports out of an excessive sense of caution.
Courtesy of a colleague

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