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There’s an epidemic of concussions across the United States, and David Cifu has issued a call to arms.
Cifu, Virginia Commonwealth University School of Medicine’s chair of physical medicine and rehabilitation, is one of three researchers behind an editorial in the August issue of the American Journal of Public Health that calls for increased funding toward research of concussions and brain injuries. It’s a common injury that’s all-too-often underreported and not always properly treated, he says.
“The epidemic of concussions (more than 4 million a year in the U.S.) is just being appreciated by the public despite nearly 30 years of outcry from specialists,” he said Wednesday in an interview conducted by email.
It’s also a call to arms, he says, to enhance public awareness of what a concussion is, and to encourage people to promptly seek proper assessment and care from a specialist (half of those who sustain a concussion aren’t seen by a clinician). He also advocates “the use of psychological services for persistent symptoms, extensive education on the injury and treatment strategies, and the long-term monitoring of patients.”
Cifu notes that proper treatment is critical, and yet too often pediatricians, general practitioners and other health care professionals may not be current on the latest therapeutic regimen, which leads to less than optimal outcomes and persistent symptoms.
So, who’s at risk?
Anyone and everyone, and anywhere. You can slip and fall, you can be in a car crash, and you can injure your head. Repeated concussions and poor management of brain injuries can lead to dementia and chronic symptoms.
Concussions are a major concern for students and other children engaged in sports. They are common in sports including football, girls' basketball, and boys' and girls' soccer, according to the Centers for Disease Control and Prevention. Football, a male-dominated sport, has gotten the headlines regarding concussions, but The Washington Post reports that girls in sports suffer a higher concussion rate than boys.
Children with concussions are generally eased back into their game, according to Douglas Cutter, a primary care sports medicine physician with HCA Virginia. They’re not allowed back onto the field before they are cleared to be back in school full time.
Each case is different, but 85 percent are better in a week to 10 days, Cutter says.
The first step in dealing with a concussion is basically a complete shutdown of activity for the child, staying at home and doing nothing: no cell phone, no television — nothing. That’s hard to do, of course, and kids don’t want to comply, but failure to do so can make a concussion last longer and increase the severity.
“You have to really let the brain recover,” says Cutter.
After that stage, students can return to class, with their activity level monitored and incrementally increased as symptoms improve. Students can be checked and cleared to return to practice and to game participation only after they are fully back in school.
“The return-to-learn and return-to-play protocols are very helpful in slowly returning the athletes to activity safely,” says Jeffrey Roberts, program director for Bon Secours St. Francis Sports Medicine Fellowship Program and a family and sports medicine physician.
A second concussion requires a longer wait, and after a third the athlete would be held out for the remainder of the season, says Cutter.
Cifu contends that treatment protocols for student athletes reduce the risk of repeat concussions, but may be too conservative. He says students should be kept from practice and game situations, but should be encouraged to return to normal activities such as classes within 24 to 36 hours, and to “push through” symptoms.
“The brain that is concussed heals best when it is fully used and stimulated (not kept quiet or put in a darkened or low-stimulation environment),” he says. “The vast majority of symptoms are due to musculoskeletal injury — whiplash, direct trauma to skull muscles — and NOT due to any underlying damage ("disconnection") in the brain. Rest is NOT an appropriate treatment; in fact it can cause harm (psychological, physical).”
TECHNIQUES AND GEAR
Head injury protection in sports is often about technique. In football, for example, you have to learn how to tackle properly to lessen the chance of head injury, and neck injury as well, says Roberts.
Rule changes have helped as well. Targeting and kickoff rules have been changed in football to lessen injury chances, and in soccer, heading has been banned from youth leagues.
There’s no good data as yet regarding whether prohibitions on heading the soccer ball has had any effect, says Roberts. He also notes that most concussions in soccer stem from other causes, including running into other players, falling, getting knocked down, etc.
Roberts says football helmets work well in protecting against skull fractures and lacerations, but not so much in warding off concussions. For that, Cutter notes, a football helmet would need foam two-feet thick to prevent a concussion, and that’s simply not feasible. Roberts also says that better headgear can make a player feel invincible, so they take more risks.
Parents need to monitor their child after they have been in a situation on the field that could result in a concussion, says Cristin Beazley, a doctor of physical therapy and clinical lead for the concussion care program at Sheltering Arms.
Symptoms can occur at any time and can be vague and hard to detect, says Beazley. Is your child acting different? Is she slower, foggier, or just doesn’t feel right?
“It’s always worth getting them check out,” she says.
Some leagues and schools call for a baseline cognitive reading of athletes for use in determining whether a concussion has led to any decline in cognitive abilities. The tests cost about $75, which can be prohibitive.
Cifu sees no need for baseline testing. He says testing should be reserved for the rare cases involving those with “persistent or worsening difficulties.”
“The overwhelming majority of individuals who sustain a concussion … will recover rapidly with early return to physical and cognitive activity, education on injury effects and treatment, physical therapy for persistent symptoms and psychological support.”
COMBAT AND CONCUSSIONS
Sports and motor vehicle accidents account for most concussions in the United States, but armed service members and veterans have sustained concussions in combat, frequently from IEDs, improvised explosive devices. The editorial authors note that 344,030 soldiers have sustained traumatic brain injuries since 2000.
Better-designed vehicles and enhanced protective gear and equipment including helmets and body armor has improved protection for soldiers, Cifu says. Treatment protocols have also been adapted to provide early and aggressive treatment in-country instead of waiting to move the soldier to a larger base or back to the states, says Cifu.
“Active management strategies” are also called for, according to Cifu, including getting the soldier active mentally and physically in a day to a day and a half, having physical therapists manage symptoms including headache and dizziness and visual tracking deficits, educating the soldier regarding the injury and strategies for managing it, and helping the soldier deal with persistent symptoms through psycho-education and counseling.
It’s a dangerous world out there, but you can’t shield your child from all the risks, nor should you try. In our sedentary world, the benefits of physical activity and team sports outweigh the dangers.
“There are risks to playing contact sports and injuries can occur with any sport, but injuries can also occur in day-to-day activities, too,” says Roberts. “That being said, exercise is extremely important and I always encourage regular exercise in everyone of all ages, but particularly kids and young adults. “I think sports offer healthy lifestyles through exercise but also teach work ethic, leadership and team-building skills. “
As Cifu notes, an inactive child who becomes a sedentary adult has a greater than 50 percent chance of dealing with conditions including heart disease, diabetes, obesity and accompanying ailments, while the risk of concussion-associated dementia is less than .001 percent.
Parents can do their part by educating themselves on brain injuries and concussions, and educate their student athlete as well. A great place to start is the CDC’s Heads Up outreach. The program offers a wealth of information on concussions and athletics, including a training class through its website.
Beazley says parents should research the sports leagues before signing up their children, to find out whether they are proactive and supportive.
Parents also should educate themselves regarding the sports program in which their child may participate. Are the coaches and participants schooled regarding concussions? Are the athletes coached in proper playing techniques, such as no head-on tackling in football? Are they encouraged to be open with one another and tell a coach if they suspect that a teammate may have a concussion?
“We need to encourage maximal participation in active play and sports,” says Cifu. “The benefits of physical activity, team activity, competition and the other key elements of sports far, far outweigh the potential effects of concussion.”
Health and medicine news in brief
- The count of cases of locally acquired Zika virus in Miami stands at 22, and it’s going to eventually spread across the southern United States. Gonzalo Bearman, an infectious disease expert at VCU Health, says his institute is prepared to provide care. Bearman chats with Anne Dreyfuss of VCU Health in a Facebook Live chat. Two takeaways: Zika is usually a mild illness in adults and older children, but has the potential for greatest harm for pregnant women and children, and the best preventative measures you can take are commonsense precautions of wearing long-sleeve shirts and long pants outdoors and to use repellents consistently and regularly.
- Registration is now open for the annual Richmond Walk to End Lupus Now. The walk will be held Saturday, Oct. 15, at the Bon Secours Washington Redskins Training Center, and proceeds will benefit lupus research and education through the Lupus Foundation of America. Call 202-787-5380 for details.
- VCU Health’s free seminars at Lewis Ginter Botanical Garden continue with a session at 5:30 p.m. on Thursday, Aug. 18, on lung cancer screening and smoking cessation. It will be led by Mark Parker, Patricia Cafaro and Michelle Futrell of the VCU Health Department of Radiology.
- Richmond’s mayoral candidates will be featured in a forum focused on how mental illness and substance abuse are affecting the community, to be held from 6 p.m. to 8 p.m. on Monday, Sept. 19, courtesy of The McShin Foundation, 2300 Dumbarton Road. The first hour will be devoted to audience members telling the candidates about community needs regarding mental illness and substance abuse. The final hour will feature the candidates giving their responses. Carol McDaid, foundation co-founder, will serve as moderator. McShin is a nonprofit recovery community organization. RSVP to firstname.lastname@example.org or call Taryn Kelly at 310-4831.
- BOHO Cycle Studio, 714 N. Sheppard St., has added a nutrition, exercise and lifestyle counseling program called BOHOCore.