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:

Background reading:

Stephens J, Salorio C, Denckla M, Mostofsky SSuskauer S (2016). Subtle Motor Findings During Recovery from Pediatric Traumatic Brain Injury: A Preliminary Report. J Mot Behav. , 1-7.

Davis KC, Slomine BSSalorio CFSuskauer 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 SHSuskauer 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 SJChristensen JR, DeMatt EJ, Trovato MKSalorio CFSlomine 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.

Suskauer SJTrovato MK (2013). Update on pharmaceutical intervention for disorders of consciousness and agitation after traumatic brain injury in children. PM R. 5(2), 142-7.

Austin CA, Slomine BS, Dematt EJ, Salorio CFSuskauer 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 SJTrovato MKZabel TAComi AM (2010). Physiatric findings in individuals with Sturge-Weber syndrome. Am J Phys Med