Traumatic Brain Injury Laws Reduce Rate of Recurrent Concussions in High School Athletes

MedicalResearch.com Interview with:

Jingzhen (Ginger) Yang, PhD, MPH Principal Investigator Associate Professor, Center for Injury Research and Policy The Research Institute at Nationwide Children’s Hospital Dept. of Pediatrics, College of Medicine, The Ohio State University Columbus, Ohio 43205

Dr. Yang

Jingzhen (Ginger) Yang, PhD, MPH
Principal Investigator
Associate Professor, Center for Injury Research and Policy
The Research Institute at Nationwide Children’s Hospital
Dept. of Pediatrics, College of Medicine, The Ohio State University
Columbus, Ohio 43205 

MedicalResearch.com: What is the background for this study?

Response: From 2009-2014, all 50 states and the District of Columbia passed their state TBI laws, more commonly known as concussion laws, to mitigate severe consequences of concussions.

These laws often include 3 core components:

(1) mandatory removal from play following actual or suspected concussions,
(2) requirements to receive clearance to return to play from a licensed health professional, and
(3) education of coaches, parents, and athletes regarding concussion symptoms and signs.

Our study aimed to evaluate whether the laws achieve the intended impact.

MedicalResearch.com: What are the main findings?

Response: The main findings showed that:

  • The rates of new and recurrent concussions initially increase significantly after a law goes into effect. This is likely due to more people – athletes, athletic trainers, coaches, and parents – becoming aware of the signs and symptoms of concussion and actually reporting a potential or actual concussion. Lack of knowledge about concussion signs and symptoms may have resulted in underreporting of concussions during the prelaw period. This trend is consistent across sports in our study and other studies looking at youth sports-related concussions.
  • The rate of recurrent concussions shows a significant decline approximately 2 ½ years after the law is in place. This demonstrates that the laws are having an impact. One of the core function of these laws is to reduce the immediate risk of health consequences caused by continued play with concussion or returning to play too soon without full recovery. The decline in recurrent concussion rates in our study is likely the results of the laws requirements of mandatory removal from play or permission requirements to return to play.
  • Football had the highest average annual concussion rate, followed by girls’ soccer and boys’ wrestling. Males had a higher average annual concussion rate than females. However, when comparing the rates in gender comparable sports (basketball, soccer, baseball/softball), females had almost double the annual rate of concussions as males. These results are consistent with findings from other studies. It is possible that girls have higher risk of concussions than boys or are more likely to report injuries. Future studies are needed to look specifically at these disparities.

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Saliva Test Can Predict Concussion Duration in Children

MedicalResearch.com Interview with:

Steven Daniel Hicks, MD, PhD Assistant Professor, Division of Academic General Pediatrics College of Medicine Penn State Health

Dr. Hicks

Steven Daniel Hicks, MD, PhD
Assistant Professor, Division of Academic General Pediatrics
College of Medicine
Penn State Health

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: There are about 3 million concussions in the US each year and the majority occur in children. Parents of children with concussions commonly cite length of recovery as a major concern, but pediatricians have no objective or accurate tests for addressing this concern.

Our research group previously identified small regulatory molecules called microRNAs that were altered in both the spinal fluid and saliva in children with traumatic brain injuries. In this study we investigated whether those microRNAs could predict duration of concussion symptoms. In 52 children with concussion we found a set of microRNAs that predict whether concussion symptoms would last beyond one month with over 80% accuracy. This was significantly more accurate than survey based tools such as the sports concussion assessment tool or a modified concussion clinical risk score. Interestingly, the microRNAs with predictive accuracy targeted pathways involved in brain repair and showed correlations with specific concussion symptoms.

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More Concussions When NFL Games Played in Below Freezing Temperatures

MedicalResearch.com Interview with:
Dr. David W. Lawrence, MD
Department of Family & Community Medicine
St Michael’s Hospital, University of Toronto
Toronto, Ontario, Canada

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Lawrence: The risk of all-cause injury and concussion for NFL athletes is significant. There has been a lot of discussion recently about this risk of injury in the NFL and general player safety, particularly regarding concussions. The first step in improving player safety and lowering that risk is to identify the factors affecting injury rates. Once we can answer those questions, we can begin to modify player exposure.

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Clinical Score Improves Prediction of Concussion Outcomes in Children

MedicalResearch.com Interview with:

Roger Zemek, MD, FRCPC Associate Professor, Dept of Pediatrics and Emergency Medicine, Clinical Research Chair in Pediatric Concussion, University of Ottawa Director, Clinical Research Unit, Children’s Hospital of Eastern Ontario Ottawa, ON

Dr. Roger Zemek

Roger Zemek, MD, FRCPC
Associate Professor, Dept of Pediatrics and Emergency Medicine, Clinical Research Chair in Pediatric Concussion, University of Ottawa
Director, Clinical Research Unit, Children’s Hospital of Eastern Ontario
Ottawa, ON

MedicalResearch.com: What is the background for this study?

Dr. Zemek: The number of concussions have dramatically increased over the past decade.  Not only are children and adolescents are at highest risk for getting concussions, they also take longer to recover.  As part of our background work, our team performed a systematic review (published in JAMA Pediatrics) confirming that validated, easy-to-use prognosticators did not exist for clinicians to identify children with concussion who are at the highest risk for persistent post-concussive symptoms (PPCS) and sequelae.

MedicalResearch.com: What are the main findings?

Dr. Zemek: In this, the largest concussion study in the world to-date, we derived and validated in a large, diverse cohort of children a clinical risk score that is significantly superior to clinicians’ ability to predict future PPCS at the time of ED presentation. Multivariate analysis revealed that age group, female sex, past history of migraine, prior concussion with symptom duration of >1 week, ED presentation with “answering questions slowly”, 4 or more errors on BESS Tandem stance, and the initial symptoms of headache, noise sensitivity and fatigue were all clinically significant and strongly associated with PCS at 1-month.

We assigned points based on the adjusted multivariate odds ratio, and the rule incorporating patient demographic factors, past history, early cognitive deficits, balance (an physical exam finding), and early symptoms.  The rule has a maximum of 12 points.  We selected two cut-off points in order to yield three clinically relevant (low, intermediate and high risk) categories for the development of PPCS at one month.

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Many Adolescents Report Symptoms Mimicking Concussions

Grant L. Iverson, PhD Director, Sports Concussion Program, MassGeneral Hospital for Children Director, Neuropsychology Outcome Assessment Laboratory, Department of Physical Medicine and Rehabilitation, Harvard Medical School Associate Director, Traumatic Brain Injury, Red Sox Foundation and Massachusetts General Hospital Home Base Program Boston, MassachusettsMedicalResearch.com Interview with:
Grant L. Iverson, PhD
Director, Sports Concussion Program
MassGeneral Hospital for Children
Director, Neuropsychology Outcome Assessment Laboratory, Department of Physical Medicine and Rehabilitation
Harvard Medical School
Associate Director, Traumatic Brain Injury
Red Sox Foundation and Massachusetts General Hospital Home Base Program
Boston, Massachusetts

Medical Research: What is the background for this study? What are the main findings?

Dr. Iverson: Health care providers rely heavily on symptom questionnaires to monitor recovery from concussion and make decisions about returning to sport after concussion.

Common symptoms of concussion include headache, fatigue, sleep problems, and difficulty concentrating.

However, many healthy adolescents, that is, with no prior concussions, report these same symptoms. It is fairly common for healthy adolescents have some symptoms in their daily life. Moreover, a subgroup of healthy high school students report multiple concussion-like symptoms, or a cluster of symptoms that look much like what we see after a concussion.

High school girls are more likely than boys to report multiple concussion-like symptoms.

High school athletes with mental health problems such as depression or anxiety, but no recent prior concussion, report a lot of concussion-like symptoms. Other prior health problems, including multiple past concussions and ADHD, had a similar but less strong association with current symptom reporting.

Girls with prior concussions might be more susceptible to the lingering effects of prior concussions. This requires further research.

Medical Research: What should clinicians and patients take away from your report?

Dr. Iverson: Be cautious about attributing symptoms that last many weeks or months following an injury to concussion, particularly in adolescents with pre-injury health problems.

When evaluating adolescents after a concussion, be sure to ask about any prior mental health problems and ADHD.

Appreciate that many factors separate from concussion can cause symptoms such as headaches, fatigue, and concentration problems in high school students.

Understand that it is difficult to know when an athlete becomes “asymptomatic” after concussion. That is, the longer a person has symptoms, the more difficult it can be to determine the extent to which those symptoms are due to the concussion or to other factors.

Citation:

Grant L. Iverson et al. Factors Associated With Concussion-like Symptom Reporting in High School Athletes. JAMA Pediatrics, 2015 DOI: 10.1001/jamapediatrics.2015.2374

Grant L. Iverson, PhD (2015). Many Adolescents Report Symptoms Mimicking Concussions 

Extracerebral Biomarkers May Not Be Optimal For Monitoring Sports-Related Concussions

MedicalResearch.com Interview with:
Pashtun Shahim, MD
Departement of Neurosurgery,
University Hospital, Linköping, Sweden
Clinical Neurochemistry Laboratory
Institute of Neuroscience and Physiology
Sahlgrenska University Hospital
Mölndal Sweden

Medical Research: What is the background for this study? What are the main findings?

Response: Visinin-like protein-1 (VLP-1 or VILIP-1) is a neuronal calcium-sensor protein, originally studied as a stroke marker and identified as a marker of neuronal injury in brain injury models. Increased plasma and cerebrospinal fluid (CSF) VILIP-1 hase been reported in Alzheimer’s disease, where CSF VILIP-1 correlates with CSF total tau (T-tau) and with brain volume. Recently, using a novel ultrasensitive method to measure tau in plasma, increased levels of plasma T-tau were found in concussed professional ice hockey players, where the levels correlated with the resolution of post-concussive symptoms and the players returning to play.

The main findings of this study were that VILIP-1 did not increase significantly in serum after sports-related concussion. However, the serum levels of VILIP-1 increased after a friendly game without concussion, signaling extracerebral expression.

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Pre-College Youth Sports Concussions Occur More Often During Practice

Thomas P. Dompier, PhD, ATC President and Injury Epidemiologist Datalys Center for Sports Injury Research and Prevention, Inc Indianapolis, IN 46202 Adjunct Faculty Appointments Ohio University Rocky Mountain University of Health Professions University of South CarolinaMedicalResearch.com Interview with:
Thomas P. Dompier, PhD, ATC
President and Injury Epidemiologist
Datalys Center for Sports Injury Research and Prevention, Inc
Indianapolis, IN 46202
Adjunct Faculty Appointments
Ohio University Rocky Mountain University of Health Professions
University of South Carolina

Medical Research: What is the background for this study?

D: Dompler: Per the Institute of Medicine’s recent recommendations to better describe the incidence of concussion in sport across the entire spectrum of youth sports (5-23 years), this study is the first to provide an apples-to-apples comparison using epidemiologic data provided by healthcare providers (athletic trainers) who attended all practices and games and used the same methodology to report concussions and student-athlete exposure information.

Medical Research: What are the main findings?

D: Dompler:
a.  The main findings are that the risk (how many players out of 100 can expect to suffer at least one concussion during the season) is lowest in the youth, and increases with age.

b. Game concussion rates (how many players out of 1000 exposed during a practice or game, includes multiple concussions to the same player) are highest in college but practice concussion rates are lowest in college during practice.  This suggests more can be done during high school and youth practices to reduce concussion frequency (e.g. limiting how much time can be devoted to full contact, reducing player-to-player contact by teaching proper tackling without using full contact drills such as the Oklahoma drill and others).

c. While the rate is higher, there is still a substantial number of concussions that occur during practice (because there are more practices), therefore sports medicine staff should be available at both if possible (this is difficult at the youth level because of cost, however).

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Law Brings More Student Athletes To ER For Sports-Related Concussions

Dr. Pina Violano, RN, PhD Trauma Department, Yale-New Haven Hospital, Injury Free Coalition for Kids of New Haven Yale-New Haven Children’s Hospital New Haven 06510, CTMedicalResearch.com Interview with:
Dr. Pina Violano, RN, PhD

Trauma Department, Yale-New Haven Hospital,
Injury Free Coalition for Kids of New Haven
Yale-New Haven Children’s Hospital
New Haven 06510, CT

MedicalResearch: What is the background for this study?

Dr. Violano: In July of 2012, Connecticut became one of the first states to enact legislation to ensure the safety and appropriate evaluation and management of sports-related concussions (SRC) among High School students. SRCs are a common occurrence in high school sports with their diagnosis increasing over the last decade. While the exact reasons are not known, public health campaign efforts and education may have facilitated improvement in the evaluation and detection of sports-related concussions and may have contributed to increase awareness and treatment.

MedicalResearch: What are the main findings?

Dr. Violano: Evaluation of two emergency department records revealed a marked increase in the frequency of high school student athletes being treated for sports-related concussions after the implementation of Connecticut’s SRC law. This suggests that Connecticut’s legislation is effective in improving the evaluation and detection of sports-related concussions in high school students.

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Concussions Raise Risk of PTSD, Depression and Anger in Returning Military Personnel

James L . Spira, PhD, MPH, ABPP Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii Director, National Center for PTSD, Department of Veterans Affairs, Pacific Islands DivisionMedicalResearch.com Interview with:
James L . Spira, PhD, MPH, ABPP
Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Director, National Center for PTSD, Department of Veterans Affairs, Pacific Islands Division


Medical Research
: What is the background for this study?

Dr. Spira:  Approximately 1.5 million Americans survive a traumatic brain injury (TBI) from traffic accidents, assaults, sports, and work injuries, with the vast majority of these being primarily mild (mTBI), otherwise known as concussion.1 Concussion, however, is uniquely problematic in the military given the new strategies of war encountered by service members when fighting an insurgency using improvised explosive devices. The rate of concussion experienced by United States (U.S.) service members engaging in combat during the wars in Afghanistan and Iraq has been estimated at between 15% and 22%.2–4There has been controversy in the area of neurotrauma as to whether persistent postconcussive symptoms (PPCSx) are due to neurological causes or solely due to the psychological sequelae of having been exposed to a traumatic event.  The recent wars in Iraq and Afghanistan have afforded an opportunity to examine these factors, although teasing them apart has proven difficult.  The most influential study of persistent effects of concussion in service members is that of Hoge and colleagues,5 in which they failed to find an independent effect of prior concussion on PPCSx, once depression and posttraumatic stress (PTSD) was taken into account.  They went so far as to recommend that assessment for concussion following deployment is unnecessary.  Others, however, have reported persistent cognitive, emotional, and physical symptoms following concussion.

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VOMS Test Better Identifies Symptoms and Impairment Following Concussion

Anthony P. Kontos, Ph.D. Assistant Research Director UPMC Sports Medicine Concussion Program Associate Professor Department of Orthopaedic Surgery University of PittsburghMedicalResearch.com Interview with:
Anthony P. Kontos, Ph.D.
Assistant Research Director
UPMC Sports Medicine Concussion Program
Associate Professor
Department of Orthopaedic Surgery
University of Pittsburgh

Medical Research: What are the main findings of the study?

Dr. Kontos: Our new Vestibular/Ocular Motor Screening (VOMS) examination was able to accurately identify nearly 90% of patients with a concussion. In our study of 64 concussed patients approximately five days post-injury and 78 healthy control-group patients who were administered VOMS by trained clinicians, we also found that more than 60% of patients with a concussion reported symptoms or had impairment on the VOMS following their injury. The VOMS, which was developed in conjunction with an interdisciplinary team of experts, assesses five areas of the vestibular ocular system: smooth pursuits, saccades (rapid eye movement), horizontal vestibular ocular reflex (VOR), visual motion sensitivity (VMS), and near-point-of-convergence (NPC) distance.

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Lacrosse Injuries Differ By Sex and Type of Play

Lara B. McKenzie, PhD MA Center for Injury Research and Policy The Research Institute at Nationwide Children’s Hospital Columbus, OH 43205MedicalResearch.com Interview with:
Lara B. McKenzie, PhD MA
Center for Injury Research and Policy
The Research Institute at Nationwide Children’s Hospital
Columbus, OH 43205


Medical Research: What are the main findings of the study? 

Dr. McKenzie: Our main findings were that lacrosse injury rates and patterns are different by sex and by type of athletic activity. Boys’ lacrosse allows for some person-to-person contact, while girls’ lacrosse largely outlaws it. Boys had an overall injury rate of 2.26 per 1000 athletic exposures, and girls had an injury rate of 1.54 per 1000 athletic exposures. The overall injury rate was about 3 times higher in competition than in practice. We also found that sprains and strains were the most common injury diagnosis for boys and girls (boys: 35.6% of injuries; girls: 43.9%), but that concussions were a significant injury diagnosis (boys: 21.9% of injuries; girls: 22.7%).
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Pediatric Trauma Center Reviews Youth Ice Hockey Injuires

MedicalResearch.com Interview with:
Stephanie F. Polites, MD
Department of Surgery and

Michael B. Ishitani, MD
Department of Pediatric Surgery
Mayo Clinic, Rochester, Minnesota

MedicalResearch: What are the main findings of the study?

Answer: Though most injuries were in boys, 20% of the injuries occurred in girls. Extremity fractures and head injuries were the most common injuries with older children and boys more likely to sustain extremity fractures while younger children and girls were more likely to have head injuries or concussions. Life threatening injuries were rare, which is reassuring.
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Concussions in Young Female Soccer Players

John W. O'Kane M.D. Associate Professor Family Medicine and Orthopaedics and Sports Medicine Medical Coordinator, U.W. Intercollegiate Athletics University of Washington Sports Medicine Clinic, SeattleMedicalResearch.com Interview with:
John W. O’Kane M.D.
Associate Professor Family Medicine and Orthopaedics and Sports Medicine
Medical Coordinator, U.W. Intercollegiate Athletics
University of Washington Sports Medicine Clinic, Seattle

MedicalResearch.com: What are the main findings of the study?

Dr. O’Kane:  In 11 to 14 year old female elite soccer players the concussion incidence was 13% with a rate of 1.2 per 1000 athletic exposures.   Symptoms lasted a median of 4 days and players with light or noise sensitivity, emotional lability, memory loss, nausea, and concentration problems took significantly longer to recover.  Heading the ball accounted for 30.5% of concussions and the vast majority of concussions (86%) occurred in games.  The majority of players (58.6%) reported playing with symptoms and less than half (44.1%) sought medical attention for their symptoms.  Those seeking medical attention were symptomatic longer and were less likely to play with symptoms.
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