Assessing traumatic brain injuries in youth athletes
Accurate identification, assessment and evaluation of concussions will enable clinicians to determine when it is safe for young athletes to return to competition.
Traumatic brain injury in youth athletes
For many young athletes, concussion or mild traumatic brain injury (mTBI), may always be a risk. However, by educating players, coaches and parents about the factors that contribute to concussions and affect recovery from these injuries, clinicians may be able to improve treatment choices and minimize the rate and severity of sports-related brain injuries in the pediatric population.
Increasing participation in youth sports can help lower rates of childhood obesity, but it also increases the risk of injuries. There are approximately 30 million to 45 million children and adolescents between age 6 years and age 18 years who participate in organized sports, and more than half of these compete in multiple sports.1 According to the National Federation of State High School Associations, approximately 7.7 million students participating in sports during the 2011-2012 school year.2
The CDC reports that sports- and recreation-related mTBIs have increased by 60% over the past decade, and emergency departments (EDs) treat an estimated 173,285 of these injuries among children and adolescents, from birth to age 19 years.3 A 2012 study looked at data from the High School Reporting Information Online injury surveillance system, a representative sample of 100 schools with injury incidence data for 20 different sports, and found that concussions represented 13.2% of all reported sports-related injuries.4
A 10-year examination of 25 high schools found that the rate of reported concussions increased more than fourfold between 1998 and 2008.5 The authors went on to note that these increases may have been partly attributable to increased awareness, reporting, and diagnosis of concussions.
Despite increased incidence and awareness of TBI in the child and adolescent population the research on sports-related concussions specific to children and adolescents is lagging behind.6
This dearth of research takes on added significance when combined with the knowledge that the evidence clearly shows that children and adolescents take longer to recover after a concussion than their adult counterparts.
What is a concussion?
The American Academy of Neurology defines a concussion as any trauma-induced alteration in mental status that may or may not include a loss of consciousness. A consensus statement released following the third International Conference on concussion in sport noted that a concussion could be defined as, “a complex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.”7 Common features that can be used to describe the nature of a concussive head injury include:
- May be caused either by a direct blow to the head, face or neck, or a blow elsewhere on the body with an impulsive force transmitted to the head
- Typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously
- May result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury
- Results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. In a small percentage of cases, however, post-concussive symptoms may be prolonged
- No abnormality on standard structural neuroimaging studies is seen in concussion7
With such diverse definitions, it is little wonder that considerable confusion about concussions exists among clinicians, researchers, coaches, parents and players.
A 2010 study highlighted a common misunderstanding about concussions. The authors noted that both professional and lay populations felt that an injury described as a concussion is less severe than one described as mTBI. This misunderstanding leads to different clinical impressions and expectations, resulting in a premature return to activity.8
Concussion will be the term used throughout the remainder of this article, but bear in mind that concussion and mTBI are to be considered the same injury.
Assessment of concussion
The signs and symptoms of concussion fall into four categories: physical, cognitive, emotional and sleep, with headache being the most reported symptom. Table 1 describes the most common signs and symptoms in each category.
It must be noted here that to have a concussion does not necessarily involve a loss of consciousness. Only 10% of concussions have been reported to have an altered level of consciousness.9 Of course, any detected loss of consciousness must be a red flag for additional testing.
The vast majority of states require high-school and middle-school athletes to undergo a pre-participation physical examination (PPE). The Preparticipation Physical Evaluation11 is an evidence-based guideline that describes how to conduct a thorough medical history and a targeted physical exam, with a focus on activity related risks to various organ systems.12 This guideline emphasizes the importance of the neurologic history and how it can provide the practitioner with information to prevent future injury.
The neurologic history can also be a good time to educate the young athlete on the significance of a concussion and how to avoid worsening of a current disability. Previous symptoms of concussions should be discussed during the PPE.
Such computerized neurocognitive programs as the Immediate Post-Concussion Assessment and Cognitive Test (www.impacttest.com) and the Axon Sports Computerized Cognitive Assessment Tool (www.axonsports.com) have been found to be valuable tools for baseline and concussion assessment. By measuring multiple aspects of cognitive activity (i.e., memory, reaction time and attention span), these tools give a quantitative assessment of an athlete's brain function.
Recognition of signs and symptoms may be difficult due to the subtlety of symptoms. Many times, athletes are reluctant to report symptoms out of fear of letting their teammates down or losing their place on the team.