Mild traumatic brain injury

Functionally-Detected Cognitive Impairment in High School Football Players Without Clinically-Diagnosed Concussion

Authors: Thomas M. Talavage, Eric Nauman, Evan L. Breedlove, Umit Yoruk, Anne E Dye, Katie Morigaki, Henry Feuer, Larry J. Leverenz.

Head trauma and concussion in football players has recently received considerable attention. Post-mortem evidence suggests that accrual of damage to the brain may occur with repeated blows to the head, even when individual blows fail to produce clinical symptoms. There is an urgent need for improved detection and characterization of head trauma to reduce future injury risk and promote development of new therapies. This study examined neurologic performance and health in the presence of head collision events in high school football players, using longitudinal measures of collision events (HIT system), neurocognitive testing (ImPACT), and functional MRI (fMRI). Longitudinal assessment (including baseline) was conducted in 11 males (ages 15-19) participating on the varsity and junior varsity football teams at a single high school. We expected and observed subjects in two previously described categories: (1) no clinically-diagnosed concussion and no changes in neurological behavior and (2) clinically-diagnosed concussion with changes in neurological behavior. Additionally, we observed players in a previously undiscovered third category who exhibited no clinically-observed symptoms associated with concussion, but who demonstrated measurable neurocognitive (primarily visual working memory) and neurophysiologic (altered activation in dorsolateral prefrontal cortex, DLPFC) impairments. This new category was associated with significantly higher numbers of head collision events to the top-front of the head, directly above DLPFC. Observation of this category suggests that more players are suffering neurologic injury than are presently detected via traditional concussion-assessment mechanisms. These individuals are unlikely to undergo clinical evaluation and thus continue to participate in football-related activities even when changes in brain physiology (and potential brain health) are present, likely increasing risk of future neurologic injury.

Brain Injury In Sports

Source: Brain Injury Resource Center

An estimated 300,000 sports related traumatic brain injuries, TBIs, of mild to moderate severity , most of which can be classified as concussions, (i.e., conditions of temporary altered mental status as a result of head trauma, occur in the United States each year.  The proportion of these concussions that are repeat injuries is unknown; however, there is an increased risk for subsequent TBI among persons who have had at least one previous TBI .  Repeated mild brain injuries occurring over an extended period (i.e., months or years can result in cumulative neurologic and cognitive deficits, but repeated mild brain injuries occurring within a short period (i.e., hours, days, weeks) can be catastrophic or fatal.  The latter phenomenon, termed "second impact syndrome" has been reported more frequently since it was first characterized in 1984.  This page describes two cases of second impact syndrome and presents recommendations developed by the American Academy of Neurology to prevent recurrent brain injuries in sports and their adverse consequences.

Traumatic Brain Injury in Children and Adolescents (Psychiatric Disorders at One Year)

Authors: Jeffrey E. Max, M.B.B.Ch., Donald A. Robin, Ph.D., Scott D. Lindgren, Ph.D., Wilbur L. Smith, Jr., M.D., Yutaka Sato, M.D., Philip J. Mattheis, M.D., Julie A. G. Stierwalt, M.A. and Carlos S. Castillo, M.D.

J Neuropsychiatry Clin Neurosci 10:290-297, August 1998 © 1998 American Psychiatric Press, Inc. 

Factors predictive of psychiatric outcome in the second 6 months following traumatic brain injury (TBI) in 43 children and adolescents were assessed prospectively. The outcome measure was the presence of a psychiatric disorder not present before the injury ("novel"). Out of six models tested, four were predictive of novel psychiatric disorder: preinjury family function, family psychiatric history, socioeconomic class/intellectual function, and behavior/adaptive function. Post hoc analyses suggested that preinjury family functioning measured by a structured interview was a significant predictive variable. Severity of injury, when reclassified as severe versus mild/moderate TBI, significantly predicted novel psychiatric disorders. These data suggest that some children, identifiable through clinical assessment, are at increased risk for psychiatric disorders following TBI.

Military Still Failing To Diagnose, Treat Brain Injuries

Authors: T. CHRISTIAN MILLER and DANIEL ZWERDLING

NPR: National Public radio June 8, 2010

The military medical system is failing to diagnose brain injuries in troops who served in Iraq and Afghanistan, many of whom receive little or no treatment for lingering health problems, an investigation by NPR and ProPublica has found.

So-called mild traumatic brain injury has been called one of the wars' signature wounds. Shock waves from roadside bombs can ripple through soldiers' brains, causing damage that sometimes leaves no visible scars but may cause lasting mental and physical harm.

Officially, military figures say about 115,000 troops have suffered mild traumatic brain injuries since the wars began. But top Army officials acknowledged in interviews that those statistics likely understate the true toll. Tens of thousands of troops with such wounds have gone uncounted, according to unpublished military research obtained by NPR and ProPublica.

"When someone's missing a limb, you can see that," said Sgt. William Fraas, a Bronze Star recipient who survived several roadside blasts in Iraq. He can no longer drive, or remember simple lists of jobs to do around the house. "When someone has a brain injury, you can't see it, but it's still serious."

Mild Traumatic Brain Injury: Neuroimaging of Sports-Related Concussion

Authors: Cecilia V. Mendez, M.D., Robin A. Hurley, M.D., FANPA, Maryse Lassonde, Ph.D., Liying Zhang, Ph.D. and Katherine H. Taber, Ph.D., FANPA

J Neuropsychiatry Clin Neurosci 17:297-303, August 2005
doi: 10.1176/appi.neuropsych.17.3.297
© 2005 American Neuropsychiatric Association

Today, multiple sports are associated with concussive events. In excess of 1.5 million people participate in football (i.e. recreational, high school, collegiate, and professional) annually. The estimated annual incidence of MTBI’s in football is 4–20%.5 A systematic review of the literature from 1985 to 2000 found ice hockey and rugby to have the highest incidence of concussion for high school, college, and amateur athletes, while soccer had the lowest.10 At the recreational level, female taekwondo participants and male boxers had the highest frequency of concussion.10 Of the injuries, 6.2% were concussive in a three-year prospective study among intercollegiate athletes.11 According to a survey of 1,659 children participating in contact sports, 3% suffered concussions.12 In addition, an epidemiologic study of collegiate and high school football players found that players who sustain one concussion are three times more likely to sustain a second one in the same season.13

Mild Traumatic Brain Injury in U.S. Soldiers Returning from Iraq

Authors: Charles W. Hoge, M.D., Dennis McGurk, Ph.D., Jeffrey L. Thomas, Ph.D., Anthony L. Cox, M.S.W., Charles C. Engel, M.D., M.P.H., and Carl A. Castro, Ph.D.
N Engl J Med 2008; 358:453-463January 31, 2008

BACKGROUND

An important medical concern of the Iraq war is the potential long-term effect of mild traumatic brain injury, or concussion, particularly from blast explosions. However, the epidemiology of combat-related mild traumatic brain injury is poorly understood.

METHODS

We surveyed 2525 U.S. Army infantry soldiers 3 to 4 months after their return from a year-long deployment to Iraq. Validated clinical instruments were used to compare soldiers reporting mild traumatic brain injury, defined as an injury with loss of consciousness or altered mental status (e.g., dazed or confused), with soldiers who reported other injuries. 

RESULTS

Of 2525 soldiers, 124 (4.9%) reported injuries with loss of consciousness, 260 (10.3%) reported injuries with altered mental status, and 435 (17.2%) reported other injuries during deployment. Of those reporting loss of consciousness, 43.9% met criteria for post-traumatic stress disorder (PTSD), as compared with 27.3% of those reporting altered mental status, 16.2% with other injuries, and 9.1% with no injury. Soldiers with mild traumatic brain injury, primarily those who had loss of consciousness, were significantly more likely to report poor general health, missed workdays, medical visits, and a high number of somatic and postconcussive symptoms than were soldiers with other injuries. However, after adjustment for PTSD and depression, mild traumatic brain injury was no longer significantly associated with these physical health outcomes or symptoms, except for headache.

CONCLUSIONS

Mild traumatic brain injury (i.e., concussion) occurring among soldiers deployed in Iraq is strongly associated with PTSD and physical health problems 3 to 4 months after the soldiers return home. PTSD and depression are important mediators of the relationship between mild traumatic brain injury and physical health problems.

 

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