concussions in childhood and adolescent athletes

As we are beginning to find out that concussions (otherwise known as TBI or Traumatic Brain Injuries) can be far more serious than anyone could have guessed just one short decade ago.  For instance, we now know that AUTOIMMUNE DISEASES are heavily linked to TBI’s.  Who would have thought?  But as the hits keep coming, the problems don’t stop there.  Although there are a myriad of symptoms associated with TBI, this article focuses on the top four, which are

• Headache  (this is the most common of the four)

• Sleep Disturbances (an inability to either get to sleep or stay asleep)

• Cognitive Deficits (slow reaction times, feeling like you are in a fog)

• Neuropsychiatric Issues (emotional reactions or lack of reaction, mood swings, irritability, rage, depression)

As the article stated, its chief thrust is to, “focus on non -pharmacologic therapy of pain after an SRC (Sports Related Concussion) because, “it is widely accepted as the most important intervention in the management of SRC” .  Furthermore, the authors (a medical student in neurosurgery, a prominent neuro-psychologist, and top neuro / orthopedic surgeon) go on to warn readers that the drugs which are typically given for those who have suffered SRC’s, “are not supported by strong evidence,” and should be used “cautiously” if at all.  All of this begs the question of what constitutes the best non-pharmacological approach to managing Traumatic Brain Injuries / Sports-Related Concussions in young athletes?   Fortunately they tell us.  But be warned.  Much of this is not the kind of thing that many athletes or coaches want to hear.

The authors tell us that the single best form of treatment for individuals who have been through an SRC / TBI, “involves physical and cognitive rest until the acute symptoms have resolved“.  They specifically mention that this means resting from things like, “homework and video games” as well as “at least 24 to 48 hours” of physical rest after the concussion.  From there, the young athlete is supposed to, “follow a stepwise graduated return to play protocol“.  As you can see, there is potential wiggle-room for coaches who want their athletes back quicker than they should (and let’s face it, as a coach myself, I can assure you that no coach likes playing without their best players on the field).  Beyond this, you have to understand that in order to get back on the field, athletes will often lie (just Google “I lied about concussions” to see how prevalent this phenomenon is in all levels of athletics).

Coaches must be educated about this — particularly the specifics of the return-to-play protocol.  My sincerest wish is that once they understand the potential for lifelong, yet often occult (hidden — at least at first) consequences of these supposed “mild” brain injuries, they will err on the side of caution.  Ethically, they must.  When you add the fact that the authors tell us that most (“80-90%“) of these concussions take “7-10 days” to recover from, due to the fact that, “athletes who have suffered previous concussions are at a significantly higher risk for incurring a repeat concussion, especially in the acute post-concussive period,” you can see the potential for disaster.

This would be as good a time as any to allow me to reiterate the “no drugs” message being touted by these authors.  After talking about some of the drugs that these children could be prescribed for their post-concussive symptoms, and then discussing the array of potential side effects, they come to a final conclusion in the paper’s last paragraph.  “The evidence behind the majority of these pharmacologic therapies is lacking…..  Non-pharmacologic therapy with physical and behavioral rest, as recommended by CISG2 should be attempted prior to the initiation of pharmacologic therapy.”  This is good advice for coaches, parents, and athletes themselves.  Just remember that your young athlete is likely to lie in order to get back on the field.  You must be aware of this fact and protect them from themselves!

This is the group (those who do not fall into the 80-90% of the previous section) for which the authors think pharmacological therapy might be warranted.  They say that individuals from this group,”should be managed in a multidisciplinary setting by clinicians with experience in sports-related concussion“.  They then go on to discuss which of the myriad of drugs out there might benefit those suffering the effects of a concussion.  Be sure to understand that before talking about the many side effects, the authors declare that, “unfortunately, there is still a lack of published evidence delineating the role of pharmacologic agents for SRCs“.

Take my word for it when I tell you that the drugs chiefly discussed in this article are for the purpose of covering the symptoms listed earlier.  This is because, “there have been few clinical trials of medications that modify the underlying pathophysiologic processes” associated with TBI’s.  This is not really news.  Ask those who have PCS (Post-Concussive Syndrome) whether the drugs really help them, and virtually all will answer in the negative (HERE IS AN EXAMPLE).  The authors do let us know that athletes on drugs for TBI caused by SRC are not allowed to return to the field / court while still on drugs.  Furthermore, because HEADACHES are the most common symptom (slightly less often, these can be MIGRAINES), I feel that I must mention that the authors concluded that they, “strongly recommend against the use of opioids in PTH [post-traumatic headache]“.  They also discussed “Rebound Headaches” (aka “Medication Overuse Headaches”) — headaches that are actually caused by the very medication(s) people take for their headaches.

The fourth item mentioned was Neuropsychiatric Issues.  The most common of these are, “depression and emotional disturbances“.  Despite the fact that the authors tell us that, “depression after SRCs usually resolves spontaneously in a short period of time,” they turn around and tout several different medications and tell us that, “SSRIs and tricyclic antidepressants should be used to treat depression related to TBIs“.  I would very much disagree with this approach in virtually all cases.  Once you understand a bit about DEPRESSION and the drugs used to treat it, you’ll not want your children on them.

I found it interesting that while they discussed INSOMNIA, they were not enamored with the drugs used to treat it.  They did promote the concept of “Sleep Hygiene,” which entails things like, “using the bed only for sleeping, avoiding coffee, alcohol, and nicotine, going to bed at the same time every night, and avoiding sources of stimuli in bed, such as televisions, computers, and mobile phones“.  Interestingly enough, they also talked about supplementing with Melatonin — a chemical made by your body to regulate Circadian Rhythms and Sleep Cycles.  I was troubled to see that they promoted RITALIN and similar drugs (HERE) for the “Cognitive Deficits” seen with TBI / SRC.

Overall, I think the article was good.  It seemed however, that despite the fact that over and over again the authors spoke about drugs not being good options for treating children with concussions, they spent an awful lot of time talking about various drugs used to treat children with concussions.  To better understand why this is, you can read a commentary I wrote on this topic a few years ago (HERE).  Honestly, the more one understands the way that EVIDENCE-BASED MEDICINE works (or doesn’t work), the less you are surprised by this frequent doublespeak.  If your child is suffering the after-effects of a TBI (whether it’s sports-related or not), have them checked out by a Functional Neurologist trained by Ted Carrick.  Trust me when I tell you that TBI’s can lead to some places you do not want your children to go (HERE).