Nov 29, 2016
Buzz on Brain Injuries

As we close out the fall sports season, concussion stories have been prominent in the headlines. Here, T&C rounds up the latest buzz, including two studies on the significance of head impacts, one on return to play following a head injury, and a new consensus on concussion treatment.

Changes in the Brain

Ask any football player, and they’ll tell you that they experience numerous head impacts over the course of a season. Although these hits don’t always result in a concussion, they may still cause structural changes in the brain, says a new study published in the journal Radiology

“Most investigators believe that concussions are bad for the brain, but what about the hundreds of head impacts during a season of football that don’t lead to a clinically diagnosed concussion?” lead author Christopher Whitlow, MD, PhD, MHA, Associate Professor and Chief of Neuroradiology at Wake Forest School of Medicine, asked in a press release. “We wanted to see if cumulative sub-concussive head impacts have any effects on the developing brain.”

To do this, researchers studied 25 male football players aged 8 to 13 over the span of a season. Using the Head Impact Telemetry System, investigators tracked the number and severity of head impacts sustained by participants. Players also underwent pre- and postseason diffusion tensor imaging (DTI).

No players were diagnosed with concussions during the season, but the DTI scans revealed athletes who suffered more head impacts had lower levels of fractional anisotrophy (FA). This refers to the way water molecules move around nerve fibers in the white matter of the brain. Reduced FA been linked with brain abnormalities.

“These decreases in FA caught our attention because similar changes in FA have been reported in the setting of mild [traumatic brain injury],” noted Dr. Whitlow.

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At this time, researchers can’t predict the effects low FA levels will have on long-term brain health, but they would like to delve further into the topic.

“We do not know if there are important functional changes related to these findings, or if these effects will be associated with any negative long-term outcomes,” Dr. Whitlow said. “Football is a physical sport, and players may have many physical changes after a season of play that completely resolve. These changes in the brain may also simply resolve with little consequence. However, more research is needed to understand the meaning of these changes to the long-term health of our youngest athletes.”

In a similar vein, a study published in EBioMedicine says heading a soccer ball can cause immediate changes in brain function—even if the impacts do not result in concussion. This is the first study to show this correlation.

As part of the investigation, 19 soccer players took turns heading a ball 20 times in a row. The ball was shot from a machine meant to mimic the velocity of a corner kick. Athletes’ brain functions were measured before and after the heading drill using transcranial magnetic stimulation, and memory tests were also given at these times.

Results showed that both brain inhibition and reduced memory occurred after one heading session, with memory test performance dropping by 41 to 67 percent. However, these effects dissipated over the following day.

“Although the changes were temporary, we believe they are significant to brain health, particularly if they happen over and over again as they do in [soccer] heading,” Magdalena Ietswaart, PhD, Cognitive Neuroscientist and Senior Lecturer in Psychology at the University of Stirling in Stirling, Scotland, said in a school press release. “With large numbers of people around the world participating in this sport, it is important that they are aware of what is happening inside the brain and the lasting effect this may have.”

While it remains to be seen whether the changes caused by heading have any long-term significance, study co-author Angus Hunter, PhD, Reader in Exercise Physiology in the Faculty of Health Sciences and Sport at Stirling, believes these results can kick-start a new dialogue.

“We hope these findings will open up new approaches for detecting, monitoring, and preventing cumulative brain injuries in sport,” he said. “We need to safeguard the long-term health of [soccer] players at all levels, as well as individuals involved in other contact sports.”

Back Too Soon

Meanwhile, when it comes to athletes who have suffered concussions, this new study found that return to play (RTP) guidelines aren’t always adhered to. In fact, 38 percent of the athletes surveyed resumed activity on the same day they were injured.

Participants included 185 concussed youth and adolescent athletes, aged 7 to 18 years. Their post-concussion RTP habits were evaluated over 10 months by researchers from Texas Scottish Rite Hospital for Children in Plano, Texas.

Early returns following concussion proved to be detrimental in the study. The 71 athletes who resumed play the same day they were concussed subsequently experienced worse symptoms than they had upon first getting injured. These individuals also reported higher rates of nausea, balance issues, and other symptoms.

Besides these negative responses, there are other more severe consequences associated with premature RTP following concussion. For example, if an athlete experiences another head impact during activity, they are susceptible to second-impact syndrome, which can prove fatal. In addition, returning too soon has been associated with increased risk for developing neuropsychological deficits.

Study authors say a key to preventing early RTP in the future is promoting the importance of a safe, thorough concussion recovery.

“We need to emphasize the message, ‘When in doubt, sit them out—and keep them out—until full recovery,’” Shane Miller, MD, FAAP, CAQSM, Sports Medicine Physician at Texas Scottish Rite Hospital, said in a press release.

Echoes co-investigator Meagan Sabatino, CCRP, Senior Clinical Research Coordinator at Texas Scottish Rite Hospital:

“Our findings suggest that we still have work to do to change behaviors to protect short- and long-term brain health of youth athletes.”

In Agreement

Elsewhere in concussion news, a group of 38 researchers has come to a consensus on the results of a symposium held at the University of Pittsburgh Medical Center in October 2015: Concussion is treatable. They’ve published their opinion in a statement of concussion treatment in the journal Neurosurgery.

“This is the very first time that a group of experts have convened and issued a statement that concussion is treatable, and the impact of that statement should not be understated,” David Okonkwo, MD, PhD, one of the primary authors and Clinical Director of the University of Pittsburgh’s Brain Trauma Research Center, told the Pittsburgh Post-Gazette. “It is exceedingly difficult to find those words—quote, ‘concussion is treatable,’ end quote—in the medical literature, and we chose to focus on that because that would be the best catalyst for what’s needed next in the field.”

The paper also contains 16 consensus statements across three topics: summary of the current approach to treating concussion, heterogeneity and evolving clinical profiles of concussion, and targeted evaluation and active management approach to concussion treatment. In addition to enforcing the idea that concussion is treatable, the statement disputes the idea that complete physical and mental rest following head injury results in optimal outcomes.

“Patients who sustain comas from major brain injuries are actively rehabilitated over many, many months,” Okonkwo said. “If it’s true for someone with a severe traumatic brain injury causing a coma, why wouldn’t it be true for a less severe injury causing a concussion? Ironically, there is no evidence to support the concept of rest in spite of the fact that it’s been the dogma of the field for a long time.”

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