Discussion 9 AHA Nervous System

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Concussion and the Adolescent Athlete Donald E. Kimbler, Marguerite Murphy, Krishnan M. Dhandapani

ABSTRACT Traumatic brain injury (TBI) is a complex and debilitating neurological injury that places a significant financial and emotional burden on both families and medical providers. Accumulating evidence suggests that mild TBI or concussion remains grossly underdiagnosed, as compared with more severe TBI, due to a poor understanding of the clinical signs and symptoms involved with a head injury. Notably, pediatric head injury may be associated with the subsequent development of serious, long-term neurological consequences, emphasizing the need for improved diagnosis and acute medical intervention. The purpose of this minireview is to summarize the association between participation in youth athletics and the occurrence of concussions, a primary source of mild TBI in the adolescent population, with the goal of increasing awareness within the nursing profession for this clinically important yet underdiagnosed form of brain injury.

T raumatic brain injury (TBI) is a leading cause of death and disability across all population demographics. Over 57 million people world-

wide live with the neurological consequences of a TBI, including 10 million people who require hos- pitalization (Zitnay et al., 2008). Within the United States, over 1.7 million Americans experience TBI annually, resulting in 275,000 hospitalizations and 52,000 deaths (Bramlett & Dietrich, 2004; Langlois, Rutland-Brown, & Thomas, 2004; Nortje & Menon, 2004). The incidence of TBI has increased more than 5% within the past decade, producing an annual eco- nomic impact of È$60 billion due to medical ex- penses and the cost of lost productivity (Faul, Wald, & Coronado, 2010; Thurman, 2001; Zitnay et al., 2008).

TBI represents a heterogeneous group of injuries that exhibit a variable, complex pathophysiology and

produce a range of long-term sequelae that include emotional disturbances, cognitive difficulties, lan- guage disturbances, and other neurobehavioral issues (Faul et al., 2010; Zitnay et al., 2008). The Centers for Disease Control and Prevention broadly defines TBI as ‘‘a bump, blow or jolt to the head or a pene- trating head injury that disrupts the normal function of the brain’’ (Binder, Corrigan, & Langlois, 2005; Faul et al., 2010); however, patient outcomes vary widely depending on the severity of the initial trauma. Moderate to severe TBIs, which are frequently caused by motor vehicle accidents or falls, may induce loss of consciousness and confusion, whereas mild TBI (mTBI) is often associated with more mild deficits and/or the lack of overt clinical symptoms. The clin- ical criteria for defining mTBI remain poorly defined; thus, many victims fail to seek and/or receive imme- diate medical attention and may experience long-term deleterious consequences as a result. Given the public health importance, improved awareness and under- standing of the signs and symptoms of mTBI are needed to improve patient outcomes.

The Problem In contrast to other common neurological diseases, such as stroke and Alzheimer disease, TBI is most prevalent in younger populations, with the 0Y4-year and 15Y19-year age groups experiencing the highest rates of incidence (Mitka, 2010). Overall, TBI is more prevalent than breast cancer, AIDS, multiple sclero- sis, and spinal cord injury combined; however, these data reflect only the number of neurotrauma patients seeking emergency medical treatment and overlook an increasing number of mTBI victims (e.g., concus- sions) who fail to obtain medical evaluation. As a result, TBI is now commonly regarded as a ‘‘silent epidemic.’’

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Questions or comments about this article may be directed to Donald E. Kimbler, MSN CRNA, at [email protected]. He is a graduate student in the Department of Neurosurgery, Georgia Health Sciences University, Augusta, GA.

Marguerite Murphy, DNP, is an associate professor in the School of Nursing, Georgia Health Sciences University, Augusta, GA.

Krishnan M. Dhandapani, PhD MS, is an associate professor in the Department of Neurosurgery, Georgia Health Sciences University, Augusta, GA.

This project is sponsored, in part, by grants from the National Institutes of Health (R01NS065172) and from the TriService Nurs- ing Research Program, Uniformed Services University of the Health Sciences. The information, content, and conclusions do not nec- essarily represent the official position or policy of, nor should any official endorsement be inferred by the TriService Nursing Re- search Program, the Uniformed Services University of the Health Sciences, the Department of Defense, or the U.S. Government.

The authors declare no conflict of interest.

DOI: 10.1097/JNN.0b013e31823858a6

Despite the prevalence within society, a relatively modest percentage of research effort has been de- voted to the mechanistic understanding and treat- ment of TBI; however, approximately 22%Y29% of all wounded soldiers from the Operation Iraqi Freedom and Operation Enduring Freedom experi- enced at least one reported TBI, making this the ‘‘signature wound’’ in current military personnel (Bradshaw, 2008; Okie, 2005). These recent findings in the Armed Services have resulted in a renewed interest in understanding the clinical pathophysiol- ogy of TBI and have raised awareness to this type of injury. On the basis of the prevalence of mTBI in soldiers, in 2009, the Department of Veterans’ Affairs put forth clearly defined clinical guidelines for TBI that included a defined characterization of TBI, as summarized below:

A traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force that is indicated by new onset or worsening of at least one of the following clinical signs, immediately following the event: 1. any period of loss of or a decreased level of consciousness (LOC), 2. any loss of memory for events immediately before or after the injury (post-traumatic amnesia (PTA), 3. any alteration in mental state at the time of the injury (confusion, disorientation, slowed thinking, etc), 4. neurological deficits (weakness, loss of balance, change in vision, praxis, paresis/plegia, sensory loss, aphasia, etc) that may or may not be transient, 5. intracranial lesion. (Management of Concussion/mTBI Working Group, 2009)

Although important for ensuring adequate care to veterans, these studies have served another impor- tant purpose in that public awareness for TBI within civilian populations has been significantly height- ened. To maintain focus and limit the scope of this mini-review, the following sections will present cur- rent data on sports-related TBI in the adolescent ath- lete because this topic is of clinical import to many nurses, trainers, and other emergency room medical personnel.

ConcussionVA Form of mTBI Historically, TBI represented an all-encompassing term covering the complete spectrum of neuro- trauma, ranging from mild to severe head trauma (Faul et al., 2010); however, this broad definition does not adequately differentiate between mTBI and severe head injury. Throughout the literature, the terms mTBI and concussion are used interchangeably (Tanielian, 2008); however, mild simply refers to the

severity of the initial insult rather than providing a predictor of the long-term sequelae (Grady, 2010). In contrast, the term concussion is more often used when communicating with mTBI patients or with families of patients because È33% of Americans are unfamiliar with the term TBI or equate this with the more severe forms of injury (Langlois, Marr, Mitchko, & Johnson, 2005). To provide further clarity and consistency within the medical community, the Academy of Neurology defines concussion as ‘‘a trauma-induced alteration in mental status that may or may not involve loss of consciousness and whose hallmark is confusion’’ (‘‘Practice Parameter: The Man- agement of Concussion in Sports (Summary State- ment),’’ 2011). Furthermore, in a 2008 consensus statement from the International Symposium on Con- cussion in Sports, concussion was defined as ‘‘com- plex pathophysiological process affecting the brain, induced by traumatic biomechanical forces.’’ This sports concussion may or may not involve a loss of consciousness and generally reflects functional dis- turbances rather than structural damage or injury. This results in the absence of abnormalities on stan- dard structural neuroimaging (McCrory et al., 2005).

Sports Concussions and the Adolescent Athlete Concussions are an increasingly common sports- related injury. The Centers for Disease Control and Prevention estimates that È135,000 children between the ages of 5 and 18 are treated in the emergency room each year for concussion as a result of partic- ipation in sports-related activities (Faul et al., 2010); however, these numbers may represent significant underestimates because recent reports indicate that È300,000Y3,800,000 sports-related mTBIs occur an- nually, with children aged 14Y19 exhibiting three times more TBI in 2007 as compared with 1997 (Buzzini & Guskiewicz, 2006; Halstead & Walter,

An ever-growing body of evidence

suggests that concussion, or

mild traumatic brain injury (mTBI),

in young individuals is an often

unrecognized or overlooked,

underreported, and inadequately

treated problem in pediatric and

adolescent neuroscience.

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2010; Mitka, 2010). It remains unclear whether the increased presentation of concussed adolescents in the clinic represents a true increase in the number of injuries or whether this reflects an increased aware- ness of the signs and symptoms of concussion. Given the potentially dire long-term consequences of con- cussion, these data indicate an alarming number of adolescents experiencing head injuries during partic- ipation in sporting activities.

Participation in youth sports and sports-related ac- tivities has risen dramatically over the past several de- cades, given the increased number of programs for both male and female youths. Furthermore, the rec- ognized benefits of physical fitness resulted in more adolescent involvement in competitive sports. Paral- leling this trend of increased sports participation, re- ports of mTBI as a result of involvement in a sporting event have also increased, particularly in contact sports such as football and ice hockey (Mitka, 2010). Despite improvements and more widespread use of protec- tive equipment (e.g., improved helmet design), which reduce the incidence of concussion, a large number of concussions occur each year, indicating a large pub- lic health need to better understand the risk factors and symptoms and signs of a concussion.

A common problem with sports-related concus- sion is that the symptoms often appear mild, lead- ing to the refusal of appropriate medical treatment by the youth; however, it is equally likely that the athlete, coaches, and/or parents do not fully under- stand how a concussion manifests. As such, the in- jured athlete, who may experience an impaired sense of self-awareness due to the concussion or disregard the severity of the injury due to a competitive drive to continue, declines medical attention and seeks to return to action, where they are vulnerable to a sec- ond head injury (Buzzini & Guskiewicz, 2006; Grady, 2010; Guskiewicz et al., 2003; Halstead & Walter, 2010; McCrea et al., 2003; McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004; Mitka, 2010). Given the recognition of the acute symptoms (e.g., confusion, anterograde or retrograde amnesia, dizzi- ness, nausea) and the growing appreciation of the long-term, irreversible neurological consequences that develop in the days, weeks, and months after a concussion, early diagnosis and medical interven- tion are of utmost importance (Grindel, Lovell, & Collins, 2001; McCrea et al., 2004; Pellman & Viano, 2006; ‘‘Practice Parameter: The Management of Concussion in Sports (Summary Statement),’’ 2011; Williamson & Goodman, 2006). The impor- tance of this is further illustrated by data suggest- ing that high school athletes require longer recovery periods from concussion as compared with adults (Field, Collins, Lovell, & Maroon, 2003).

Football as a Primary Source of mTBIVLessons From Professional Athletes Concussions occur in nearly all adolescent sporting activities; however, athletes participating in com- bative sports are not surprisingly at the highest risk for sustaining concussion (Grady, 2010; Meehan, d’Hemecourt, & Comstock, 2010; ‘‘Practice Param- eter: The Management of Concussion in Sports (Summary Statement),’’ 2011). In 1994, the National Football League (NFL) recognized that concussions represented a major issue in athletes, resulting in the formation of a committee to study the issue of con- cussion in professional football players. On the basis of the recommendations of the NFL, helmets and mouthpieces were redesigned to provide improved safety and helmet-to-helmet contact was banned (Pellman & Viano, 2006). However, in the past sev- eral years, a large number of former NFL players reported neuropsychiatric disorders, including in- creased aggression, erratic behavior, and suicidal ten- dencies (Solomon, Ott, & Lovell, 2011). Although the precise causes of these neurological deficits remain under intense investigation, repetitive mTBIs over the career of the athlete (which may have been undiag- nosed or unappreciated at the time of the injury) may result in the development of chronic traumatic en- cephalopathy (CTE), a progressive degenerative dis- ease that is related to dementia pugilistica in boxers. Indeed, very recent postmortem brain analysis dem- onstrated this devastating condition in at least a dozen former professional athletes, including retired NFL players, as well as numerous former ice hockey players in the National Hockey League (Kusinski, 2011; Schwarz, 2010a). Perhaps more troublesome and most relevant to the present review, a 21-year- old collegiate football player with no prior history of depression suddenly experienced an emotional col- lapse and committed suicide. Postmortem analysis of his brain revealed the development of early-stage CTE (Schwarz, 2010b). Although a causative link between CTE and suicide remains speculative in this individual, this case study suggests that even ama- teur athletes may be susceptible to the long-term con- sequences of concussion.

The sobering studies presented in the preceding section on professional athletes illustrate that ado- lescent athletes who participate in contact sports may be at risk for concussion and subsequent neurological deficits. In response to the emerging data on concus- sion, the National Collegiate Athletic Association, the primary governing body of athletics for over 1,200 colleges and universities within the United States, commissioned a study focused on the incidence of concussion and recovery times for returning to play for college football players (Guskiewicz et al., 2003).

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This study looked at the incidence of concussion in all levels of collegiate athletes (divisions IYIII, in- cluding scholarship and nonscholarship athletes) and determined that linebackers (a defensive player who delivers violent, high-impact tackles to stop the ad- vancing offensive player) experienced the highest rate of concussions at 0.99 concussions per athlete exposure, whereas wide receivers (an offensive player responsible for catching passes, typically does not involve significant contact) exhibited the lowest in- cidence at 0.53 concussions per exposure. Interest- ingly, it was determined that athletes experiencing a concussion had a higher risk of experiencing addi- tional concussions (placing these athletes at a higher risk of developing CTE and other long-term neuro- logical deficits). Furthermore, these players experi- enced longer recovery times after the first concussion and displayed cerebral dysfunction, even in cases that lacked loss of consciousness, confusion, or amnesia (Guskiewicz et al., 2003; McCrea et al., 2003).

High School Athletics and Concussion Of the estimated 300,000 sports-related concussions, approximately 250,000 occurred in football players alone (Grindel et al., 2001). Notably, È3%Y6% of all high school football players reportedly experi- enced at least one concussion; however, it is im- portant to note that these data rely upon surveillance studies and do not include reports by the players, suggesting an underestimation of the actual inci- dence (McCrea et al., 2004). In support of this asser- tion, surveys of high school football players found that two thirds of the players would not report or would mask the symptoms of a concussion due to pressure and/or a personal desire to continue playing or due to a belief that the injury was not serious enough to warrant medical evaluation (McCrea et al., 2004; Williamson & Goodman, 2006). In addition, over one third surveyed did not realize that they sus- tained a concussion until a definition was provided. Thus, when correcting for these confounds of personal reporting of head injury, the true incidence of sports- related concussions in high school football players may approach 15% per season (McCrea et al., 2004).

Although football is the primary source of adoles- cent concussion (Grindel et al., 2001), all high school athletes of both genders are at risk for concussion. Along these lines, reports from the late 2000s indicate that after football, the rate of concussions was next highest in female soccer players. In contrast, volley- ball and baseball athletes displayed the lowest in- cidence of concussion per 1,000 athlete exposures (Halstead & Walter, 2010; Meehan & Bachur, 2009). Because the incidence of concussion is generally calculated from studies involving physician visits

or following athletic trainer reports, these reports may largely underestimate the actual number of in- cidences. As sports medicine professionals generally agree that the incidence of sports-related concussions in the adolescent is significantly underreported, the numbers may represent gross underestimations, par- ticularly in ‘‘noncontact sports,’’ where the presence of qualified medical staff may be absent due to lim- ited budgets (McCrea et al., 2004; Williamson & Goodman, 2006). Furthermore, increased awareness of concussion among medical personnel and the general public may improve reporting of head injury and may provide more accurate data on the prevalence.

Discussion and Summary An estimated 300,000Y3,800,000 sports-related concussions occur annually, suggesting that mTBI in the adolescent athlete is a common occurrence (Halstead & Walter, 2010; Levy, Ozgur, Berry, Aryan, & Apuzzo, 2004). Because serious and irreversible neurological deficits are possible after repeated con- cussions, a major public health issue clearly exists. Unfortunately, clearly defined clinical definitions and practice guidelines for a concussion remain poorly accepted throughout the medical community, contrib- uting to poor public and professional awareness of this devastating and often undiagnosed injury. Com- pounding these issues is a lack of accepted structural deficits or biomarkers to definitively diagnose a con- cussion (McCrea et al., 2004; Streeter, 2011). Thus, concussion remains underdiagnosed, leaving ado- lescent athletes at a greater risk of subsequent head injuries and poor long-term outcomes (Buzzini & Guskiewicz, 2006; Grady, 2010; Guskiewicz et al., 2003; McCrea et al., 2003, 2004).

Future Directions Research studies on the effects of concussion and development of CTE are desperately needed to de- fine the clinical course of neurological dysfunction, including prospective studies to delineate the short- and long-term effects of concussions in the adoles- cent brain (Buzzini & Guskiewicz, 2006). Multiple guidelines and concussion grading systems exist to assess fitness to return to athlete competition in adults; however, these tests lack of sport-wide standardization and are not specific to the adolescent brain (Buzzini & Guskiewicz, 2006; Grindel et al., 2001). Improve- ments to these assessments, and education of nursing and other medical professionals, including nonbiased adolescent-specific recommendations, are therefore needed to provide outstanding care of the young athletes, who may be the most vulnerable to the long- term consequences of a concussion.

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