Over the muddy school fields where children jostle for glory, a growing menace looms. Sports-related concussion has, thanks to surging awareness of the condition, become an increasing worry for parents, teachers and grassroots stars.
The response has been multipronged; head-guards have been encouraged, rules have been changed and scientists have been busily working on new pitch-side tests.
Most of the research focus has been on what happens inside the white lines and immediately after. But experts at a pioneering facility in the US are now looking at childhood concussion long after the initial flashpoint – and may well have made an important breakthrough.
They are delving deeper into the fact that many children who have clinically recovered from concussion may have lingering problems, often only detectable by neuroimaging technology.
Better identifying them could be crucial in shaping post- concussion therapy and recommendations about returning to sport. They may also help to develop early bio-markers to long- term problems that may arise years after a childhood concussion.
The research is led by Dr Stacy Suskauer (pictured), research scientist at the Kennedy Krieger Institute in Baltimore.
It is monitoring what happens in adolescent brains after the ‘all clear’ has been given following a concussion.
She says: “Preliminary data suggests that children have lingering subtle motor dysfunction after concussion and are at a higher risk of musculoskeletal and concussion injuries when they return to play.
“We also have preliminary data that suggests motor dysfunction is associated with changes in activation patterns in the motor network of the brain.”
Recovery from concussion is currently assessed using behavioural measures including reports about how a child acts, feels and performs in tests of cognitive skills, balance and motor speed.
None of these measures show how the brain is working to produce these behaviours. Suskauer says: “If a child appears to have recovered after concussion, but we find out that their brain is actually working harder to achieve a particular behaviour or, essentially, compensating, then an extra concussion in the future may mean they cannot compensate as much.”
As well as influencing post-injury advice on when to return to play, researchers are hoping to find a way to better predict long- term complications; namely from Chronic Traumatic Encephalopathy (CTE).
“Some alteration in functional brain connectivity patterns could perhaps be an early warning sign that the child’s brain activation is already changing. More hits sustained after that, on top of ageing which is another hit to the brain, may mean their brain can’t compensate as well.
“We also see a number of children who appear to initially recover after concussion but maybe after three to six months have the onset of anxiety or depression. So we are also trying to understand if we can find out more about the biology behind that.”
Suskauer was involved in a preliminary study which evaluated 15 adolescents with sports-related concussion at two weeks after their injury – and again after around a month. Those not deemed to have recovered by the second visit had a further assessment after their clinical recovery.
They were measured against the Physical and Neurological Examination of Subtle Signs (PANESS) scale and compared to age and sex-matched non-concussion individuals. Adolescents with concussion had a poorer PANESS performance than the control group at all stages, including after their apparent recovery. They did, however, improve between assessments.
Suskauer is principal researcher on the new, larger scale study, which is funded by the US agency, the National Institutes of Health.
It aims to build on these findings by using functional MRI to evaluate brain functioning in children who have recovered from concussion. Measurements will be taken at the time of recovery from concussion, then three and 12 months after recovery. Behavioural assessments will also be carried out at these intervals.
“We are also collecting data on additional injuries experienced during the year, in order to preliminarily evaluate whether motor function and / or imaging patterns predict who will be injured.
“My hope is that the next level will be to develop more biological markers [for long- term concussion problems]. I also believe in another generation we will be looking at genetic markers. I believe genetics must have some influence on outcomes from concussion or multiple concussions.”
In the meantime, Suskauer is busy in her role as co-director of the Kennedy Krieger Institute’s Center for Brain Injury Recovery. The centre’s approach to concussion is, she believes, a rarity in that every child with concussion is seen by both a neuropsychologist and medical physician on every visit.
“In the US, concussion clinics tend to be run by either neuropsychologists or physicians. If the neuropsychologist can’t prescribe medication for their headaches, they may be referred to a neurologist who has lots of appointments. Parents might receive conflicting advice and it could be left to them to sort out a way forward.”
Concussion has soared up the public health agenda in America in recent years. Mostly this has been fuelled by the NFL’s escalating CTE epidemic.
Post-mortems have confirmed CTE in scores of players, while many ex-pros believe they are living with the symptoms of the disease. In 2017 neuropathologist Ann McKee examined the brains of 111 deceased NFL players – only one of them did not have CTE. Football as defined on the UK side of the pond is also facing up to a CTE crisis, with repeated heading of the ball being linked to an increasing number of dementia cases.
This came after a coroner ruled in 2002 that the dementia that killed former England star Jeff Astle was caused by “industrial disease” triggered by heading footballs.
Against this mass awakening to the dangers of impact sport, a seemingly safer alternative has blossomed. Having emerged out of grassroots, flag football now has its own national US league with a growing stable of teams.
The American football equivalent replaces tackling players to the ground with swiping a flag or flag belt from the player with the ball.
Suskauer says: “Sports can play a critical role in a child’s life in terms of physical activity and socialisation. We help each family consider the risks and benefits to their child of continued sports participation and respect that ultimately parents will decide what is best for their children.
“Ongoing efforts toward examining how to make sports as safe as possible, whether through improved safety equipment or changes to exposure to contact, represent an important component of concussion prevention.”
As with any country, measuring the scale of concussion in the US accurately is difficult given the variability of when and where care is sought.
“One group has estimated that there are one to two million sports and recreation-related concussions in children each year in the US, and this does not include the large numbers of concussion that occur outside of sports activities.
“Overall, numbers of concussions have increased, despite decreasing rates of participation in organised sports. Public awareness has improved though there is still inconsistency in identification and management of concussion, including in schools. All US states have some legislation related to childhood concussion, with the goal of minimising morbidity and mortality related to concussion.”
Suskauer was part of the team that recently published the first US-based guidelines for the evaluation and management of all childhood mild traumatic brain injuries (including concussion). It is hoped that they might help to improve standards of concussion care across the US.
“While many academic centres are at the forefront of developing and consuming the growing evidence related to concussion, this is not possible for paediatricians and practitioners. Additionally, while large cities may offer multiple options for specialty concussion care, this is not available in rural settings.
“In particular there is growing evidence supporting the limiting of strict rest after concussion and encouraging a gradual and supported return to safe activities as tolerated. We find this typically demands an individualised approach to each child.” Achieving this approach is a significant challenge, however.
“One of the limitations in the States is that children might only get 10 minutes with their primary point of care, such as a paediatrician or their family doctor. It is more likely that this will result in a single approach such as ‘just stay home from school’ rather than a tailored plan that is possible when there is time to sit down and carefully consider each child’s situation.”
Hear from a global pioneer in child brain injury care
Dr Stacy Suskauer is heading to the UK later this year to share insights drawn from an illustrious career in child brain injury care and research.
She is among the esteemed line-up of speakers at the National Paediatric Brain Injury Conference 2019 in London on 6 September, delivered by the Children’s Trust in partnership with Irwin Mitchell.
This year’s event aims to take a visionary look at what the future holds, under the banner of: ‘Building the future of childhood brain injury: where do we go from here?’
Suskauer’s presentation will focus on diagnosis, evaluation and treatment of children with disorders of consciousness. She will share some of her research in this area, looking at short and longer term outcomes and the development and validation of behavioural assessment techniques.
As co-director of the Center for Brain Injury Recovery at Kennedy Krieger, Suskauer oversees clinical services and provides direct care to children with acquired brain injury of all severities.
Under her leadership, the institute’s Rehabilitation Continuum of Care has expanded to include successful programmes for children with concussions and those with disorders of consciousness.
As director of the Brain Injury Clinical Research Center at Kennedy Krieger, she is also the principal investigator on a number of studies. Her overriding research focus is to better understand and improve outcomes after childhood brain injury.
Early bird tickets for the Children’s Trust conference, at London’s Royal Society of Medicine on 6 September, are available until 15 April. To book visit: www.thechildrenstrust.org.uk/conference.
Links to more of Dr Stacy Suskauer’s research:
- NIH Awards Funds from NFL Donation to Kennedy Krieger for New Concussion Research Study
- Children, ages 10-17, with traumatic brain injury
- Children, ages 8-18, who have had a traumatic brain injury
- Right-handed teenagers, 13-17 years old, with a sports-related concussion
- Right-handed teenagers, 13-17 years old, who have never had a concussion
Stephens J, Salorio C, Denckla M, Mostofsky S, Suskauer S (2016). Subtle Motor Findings During Recovery from Pediatric Traumatic Brain Injury: A Preliminary Report. J Mot Behav. , 1-7.
Davis KC, Slomine BS, Salorio CF, Suskauer SJ (2016). Time to Follow Commands and Duration of Posttraumatic Amnesia Predict GOS-E Peds Scores 1 to 2 Years After TBI in Children Requiring Inpatient Rehabilitation. J Head Trauma Rehabil. 31(2), E39-47.
Risen SR, Barber AD, Mostofsky SH, Suskauer SJ (2015). Altered functional connectivity in children with mild to moderate TBI relates to motor control. J Pediatr Rehabil Med. 8(4), 309-19.
Kramer ME, Suskauer SJ, Christensen JR, DeMatt EJ, Trovato MK, Salorio CF, Slomine BS(2013). Examining acute rehabilitation outcomes for children with total functional dependence after traumatic brain injury: a pilot study. J Head Trauma Rehabil. 28(5), 361-70.
Austin CA, Slomine BS, Dematt EJ, Salorio CF, Suskauer SJ (2013). Time to follow commands remains the most useful injury severity variable for predicting WeeFIM® scores 1 year after paediatric TBI. Brain Inj. 27(9), 1056-62.
Suskauer SJ, Trovato MK, Zabel TA, Comi AM (2010). Physiatric findings in individuals with Sturge-Weber syndrome. Am J Phys Med
Now is the time to embrace better ways of working
By Merryn Dowson, assistant psychologist and part of the team behind rehab goal-setting platform Goal Manager
A stitch in time saves nine. Rome wasn’t built in a day. The best things take time.
We are all too aware that some of the most important parts of our lives have been crafted, carved and developed over months and years. Consider your education, for example: you may well have been to primary school, secondary school and then sixth form college. Perhaps you went on to do an undergraduate degree.
You may even have taken another leap and completed a Master’s degree or a Doctorate. This took years. You learned, revised, sat exams, sat resits, applied for places, got results, got rejected, got accepted, and made it here.
One thing is certain: compared to all of this expertise, someone who completed a two-hour online course on the same topic does not come close. We know that putting time and effort into something gives us better results than if we tried a quick approach.
We do not always lead by this example though. Despite the knowledge that great results are only achieved through hard work and perseverance, sometimes we decide just not to bother. Often, a room in our home might look cluttered, worn down and unloved and it could be made to look incredible.
The walls could be painted, clutter cleared, carpet cleaned, furniture patched up, curtains updated, but it is so much effort. We see the effort it would take and keep living with it. It does the job. It’s fine.
We heard this a lot when we began to develop our software. Goal Manager was designed from within a clinical neuropsychology service with young people with acquired brain injury, and we recognised how goal setting was becoming an intimidating concept within our service and our colleagues across the field.
To combat this, we developed an online goal-setting platform which streamlines the key processes of goal setting into one system and allows members of multi- disciplinary teams (MDTs) to collaborate on goal data remotely.
Crucially, it was designed to fill a hole. The more daunting goal setting became, the more it was shied away from, and the guidelines for goal setting that had emerged from the literature were falling to the wayside.
While we designed our platform to save time on completing all of the gold-standard processes of goal setting compared to doing them manually, we found that people had often not been completing them at all. It was all too complicated.
As a result, we recognise that adopting a software solution like Goal Manager can come with its own problems to solve. It requires relearning a lot of
what we know about a concept like goal setting, understanding properly how these key processes work and how they can be applied clinically to benefit clients.
It is only then that you can start to think of ways to make it more efficient. To help with this, our users are offered bespoke demonstrations, guided MDTs through meetings to help with the clinical application of the data, and training on assessments and goal attainment.
This takes time. Our users are often throwing out their previous guide and writing a new one. When surveyed, however, every single one who responded said that it was worth it.
This brings us back to where we started: the best things take time; Rome was not built in a day; a stitch in time saves nine. By taking time to develop an understanding of goal setting and being able to apply it to a software solution, users experience all of the benefits of best-practice goal setting outlined in the literature both for their clients and for their teams.
Clients are motivated, rehabilitation is meaningful, important areas to address are highlighted, MDTs are focussed, clinical practice is evidenced – the list continues. None of this would have been possible without the initial investment of time.
While simple enough to read, this is no doubt overwhelming to apply to your service or practice and, with this in mind, there are some key points to remember. The most significant is that there is no better time than now.
The world is slowly opening its eyes, sitting up in bed and having a good stretch after the darkness of the Covid-19 lockdown. It is not yet certain if we are going back to snooze or if we are leaping out of bed afresh.
What we do know, however, is that we are heading into a brand new day. Even for those of us who continued in practice throughout the pandemic, services have been slightly paused in one way or another, whether that be refraining from home visits or having fewer people in the office.
We are all very aware that we are heading into the “new normal” rather than our old ways. Use this time to bring new and innovative ways of working into your practice. You might completely change your filing system, consider how you approach your waiting lists, or change how you approach MDT meetings.
Whatever you have been wanting to do for you and your service for so long, now is that time.
Perhaps you decide that you are going to welcome change but not all at once. That works too! For users of Goal Manager, we often suggest that starting with one or two clients might feel more manageable than a whole caseload.
This can help get to grips with the new concepts and ways of working without feeling like everything is completely disrupted. This applies elsewhere too. If you are wary of integrating a system into your whole service, start with one corner of it, evaluate, take what you have learned and then look to apply it more widely.
Finally, remember that all time taken to improve and grow impacts more than just what you set out to do. When people lose weight, they rarely conclude
by saying they just lost weight: they often enthuse about how they feel more energised or move easier or feel more positive or experience less anxiety.
This applies to any time you invest in developing your clinical practice or your service.
While time spent learning how to use Goal Manager and establishing it within a caseload is designed to improve goal setting, that investment also leads to improved assessment processes, more effective meetings, improved digital literacy, increased patient involvement and so much more.
The potential is enormous. To motivate you to start the process, look at what you want to achieve and how that might trigger other improvements.
While the world is still trying to drag its head off the pillow to open up the lockdown curtains, look to invest in addressing those needs you have always been aware of but never felt like you could justify the time.
Walk around your “house” and look into each room: is this the best it can be or could I give it a lick of paint?
Is now the time to bring meaningful solutions into my practice? Maybe grab a tester pot and try a new shade on the walls. Sign up for a free trial. Plan to grow and improve. Start building Rome.
To invest in improving your goal setting, visit www.goalmanager.co.uk to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.
Researchers unlock key prognostic tool for brain injured patients
In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.
The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.
The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.
However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.
When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.
“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.
“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”
But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.
The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.
Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.
“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,” Brennan says.
To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.
These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.
The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.
Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.
“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.
“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”
“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.
“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”
The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.
“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.
“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.
Update:concussion in sport
A run through the latest developments in concussion in sport research and protocols.
A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.
Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.
“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.
“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”
Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.
Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.
Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.
Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.
“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”
The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.
The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.
Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.
These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.
The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.
Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.
“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”
A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.
There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.
A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.
EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.
This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.
This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.
SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.
“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”
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