MISSING IN ACTION:  OTHER GROUPS AT RISK OF CONCUSSION

 

CONFERENCES
TOPIC: HEAD-INJURY

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Abstract

While general awareness of TBI has increased over the past decade, "missing in action" have been four areas highlighted in this lecture as in need of  attention.  Underpinning all four areas is a need for the public as well as professional groups, to made more aware of the possibility TBI or concussion as the cause of sudden behaviour change, especially since neurological symptoms can often mimic symptoms of psychopathology.  Failure to correctly attribute symptoms can unnecessarily delay treatment and rehabilitation.  Particular groups vulnerable to this misattribution are older adults, children, and sports players.  Attention is drawn to the need for uniform measurement of degree of TBI and guidelines for stand-down periods within the sports arena.  Finally, the particular dangers of sustaining multiple TBI, particularly those occurring close together in time are highlighted.
 

Awareness of traumatic brain injury (TBI) as a leading cause of neuropathology has increased markedly over the last 15 years. In western countries, it is now well accepted that young men particularly those aged between 15 and 24 years, of lower socioeconomic and educational status are at highest risk of TBI, especially if they drink and drive (1-5). This increase in awareness has been largely due to a huge upsurge in research and publications on TBI in the form of books and journals, as well as to road safety advertising and legislation in many countries making the wearing of seatbelts and cycle helmets compulsory. Traumatic brain injury, the once "silent epidemic"(6), is now the very prominent focus of professional, research and media attention. That is not to say that the epidemic is over, but rather that awareness of its cause, nature, outcome and treatment is at an all time high.  More are seeking or coming to medical attention to receive care and treatment in a vastly increased range of rehabilitation programs than ever before.  And the evaluation of rehabilitation outcome has become the new focus of research attention.

In spite of improved awareness however, those who sustain mild traumatic brain injury (MTBI) are still more likely to be overlooked than those with severe head injuries who more typically come to medical attention (2). Often the symptoms of MTBI, such as headaches, dizziness, visual problems, sleep disturbance, intolerance of noise and/or lights, fatigue, memory and concentration difficulties, impaired verbal retrieval, and emotional distress (8-10) are attributed to something else e.g. psychological stress and general ill health (2,10).  This is particularly so because the difficulties may only become apparent in the days and weeks well after the MTBI as day-to-day routines are slowly resumed (5).  This faulty attribution is likely to be reinforced if measures of psychopathology such as the SCL-90-R (11) and MMPI (12) are administered.  Considerable research has emerged recently warning that physical symptoms can mask as clinical symptoms, i.e. suggesting that psychopathology exists when it does not (13-16). Failure to correctly attribute difficulties to TBI not only delays rehabilitation but means that an individual may inadvertently place themselves at risk of further MTBI

This presentation will highlight four areas which TBI is still likely to be overlooked,  under-rated and "silent".  Current research findings pertaining to these areas  is presented.  The areas, which are not all mutually exclusive, involve children, athletes, the elderly and those sustaining multiple TBI.
 

TBI in children and older adults is more likely to occur due to falls and collisions than motor vehicle accidents (17). Children sustain accidents often during sport and play, whilst away from home.  They fall from heights whilst climbing and from bikes, skateboards and horses and collide playing sport and during the rough and tumble of play.  If an injury appears mild and is accompanied by little or no apparent physical injury, the MTBI may fail to come to medical attention.  If the injury was sustained while the child was engaged in some activity that they would rather not admit to, then the injury might not come to attention of parents or teachers either. It is much easier to cover up after MTBI than it is when there is overt evidence of injury. Yet grazes, cuts, bruises and fractures resolve far more reliably than the outcomes of MTBI.

In a study of head injury amongst 156 adolescents in New Zealand (18), 40% of respondents reported having experienced at least one mild head injury within the preceding 3 years.  While it was reassuring to determine that only a few had experienced short-term effects, and even fewer any long-term effects, there were some cases of concern.  Three children reported experiencing difficulty of the kind associated with post-concussive syndrome, which in each case was supported by neuropsychological assessment.  In only one of these cases had the difficulties been picked up parents and teachers.  There is concern then for the children who not only fail to come to medical attention but who fail to come to the attention of parents and teachers either (18-21).  For in such cases, decline in behaviour or academic performance is likely to be viewed as a failure in the children themselves.  And such attribution is only likely to confuse and alienate the child.

It is not suggested here that all children will experience difficulties after MTBI or even more severe TBI.  Most fully recover.  Rather, there is a need to urge all who deal with children, not only parents but all professionals coming in contact with children, e.g. education, health, law enforcement and sports administration, to consider and exclude TBI as a possible contributor to a sudden negative behaviour change.
 

Approximately 300,000 sports-related TBI are sustained annually in the United States (22-23).  Awareness of these statistics has generated a surge research in this area.  This has been particularly with regard to elite teams in such codes as American football, soccer, equestrian eventing, boxing, rugby and rugby league, ice hockey, the marital arts and high platform diving (24-26). Although the risk of an athlete sustaining a mild brain injury is between 2-10% for high contact sports such as rugby, boxing, and rugby league, the risk increases to as much as 25% (27).   Further in some sporting codes such as cricket, and golf whilst the incidence is low, the velocity of injury is high, (up to 80-120 km/hr).

Despite rising concern, accurate rates of sport-related TBI have yet to be clearly established, for two main reasons.  Firstly, there is considerable confusion concerning the definition of concussion and diagnosis can be made with any one of 16 classification systems ranging from three to six grades of severity (28).  The absence of a standard definition for concussion and the proliferation of so many protocols for initial head injury assessment has made it difficult to compare research studies and diluted the impact of findings.

The major second factor influencing rates of sports-related TBI concerns accuracy of reporting. Players, coaches, referees and administrators may be at times reluctant to draw attention to suspected TBI, for fear of the consequences of removing the athlete from the current or subsequent competition (27). Fears include not wanting to let the team down, being seen as weak, losing a place in the team in the future, losing the self esteem associated with playing and losing financially if playing is linked directly to remuneration. As noted for children, increased awareness about the symptoms and dangers of TBI on the part of players as well as those involved in the administration of the sport may go a long way to detecting and monitoring the symptoms of MTBI associated with sport.  This would require a significant change in the mind set against reporting, that is currently apparent from preliminary analysis of data in a study of club grade rugby underway in New Zealand. (29).
 

Incidence figures on TBI show peaks in the very young, the 15-25 year group as stated earlier and in older adults.  This is especially so for the very old who like young children sustain injuries in falls more than any other age group (30). In general, TBI for older adults is associated with increased morbidity and mortality,  longer hospital stays, higher frequency of discharge to continuing care facilities, increased disability and decreased likelihood of return to work (31).  Further having experienced prior TBI in older adults has been associated with increased risk of subdural hematoma, intracranial haemorrhages, and post-traumatic infections.

Of the many causes of TBI, falls are high likely to account for "silent" TBI, particularly those sustained by older adults.  Minor falls, and blows to the head may be overlooked because the person concerned lives alone and attaches no significance to it. In instances, when the changes are noticed, they may  be attributed to the normal consequences of aging, or to a deterioration of a pre-existing neurological condition, such as stroke or dementia.  In such instances, the older adult concerned may incapable of describing or be unaware of the nature of TBI related difficulties.   And sometimes medical attention may not be sought because of the financial cost involved.  When the fall does come to medical attention, perhaps because it was more obvious and serious, attention may be focused on the more obvious physical injuries the (e.g. a broken hip) and TBI again overlooked.

Careful neuropsychological assessment can assist in the differential diagnosis between the cognitive sequalae of TBI in older adults, normal aging and dementia especially with emphasis on group differences on measures of memory, verbal fluency and executive functioning. (32).  Early and accurate detection is imperative to ensure that appropriate intervention is instigated quickly (33).
 

An individual who has sustained one concussion is twice as likely to sustain another and after a second is 8 times more likely to sustain a third. (34).  The same individual is also at greater risk of sustaining other injuries simply due to the slowing in reaction times and poor decision making that occurs as a result of a concussion.  Multiple TBI can occur at any age, but is of most concern when the TBI are closely related in time (22-23).  Recent studies (35-36) have demonstrated that the severity of accident causing the second TBI is typically lower that the first.  For example, an individual sustaining a moderate TBI (knocked out for 5 minutes) due to a fall from a ladder onto a concrete floor may sustain a second equally severe TBI, simply from a glancing blow on a door frame.

In some instances a second concussion will result in second impact syndrome, which occurs when an individual sustains a second brain injury prior to resolution of symptoms from the first.  The syndrome typically results from a lethal combination of massive brain swelling, increased intracranial pressure and subsequent herniation (37). The seriousness of the syndrome underscores the need to recognise brain injury in the first place.  This is particularly so in "at risk" groups, such as in high contact sports.  Recognition of TBI, and restricting head-injured athletes from returning to competition too soon after sustaining an initial concussion is of high priority.  Improved recognition and monitoring of TBI in all groups is essential to lower the risk of multiple TBI.
 

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