More brain injury awareness needed to curb concussions, CDC says

The agency says such injuries are a public health issue and that surveillance should be improved to better identify and monitor cases.

By — Posted July 29, 2013

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Sports medicine physician Joseph H. Rempson, MD, received several concussions as a soccer player in high school and college in the late 1970s and early 1980s. At the time, such head injuries commonly were dismissed as “getting your bell rung.”

After the dazed feeling wore off, “we just got back in the game and played,” said Dr. Rempson, chief of the Dept. of Rehabilitation at Overlook Medical Center in Summit, N.J. “We had persistent headaches … [and] we had A students who became C students, but we didn't know what the problem was.”

In recent years, the medical community and the rest of the nation have gotten a better understanding about the severity of such injuries and their lasting impact. During the past decade, public awareness and concerns about traumatic brain injuries have surged, due in part to the identification of a progressive brain disease among more than 40 former National Football League players and reports of more than 200,000 cases of TBI in members of the U.S. military.

The Centers for Disease Control and Prevention has advocated that TBIs, including the more mild cases known as concussions, should be considered a serious public health problem. Although efforts have been made to improve prevention and early treatment of these injuries, a new CDC report says such measures don't go far enough.

“TBI is an important public health problem that requires more attention, societal engagement and research,” said the report, posted online July 12 in the CDC's Morbidity and Mortality Weekly Report.

A move to examine outcomes

The agency is calling for improvements to injury surveillance systems that report national and state TBI data. Those changes would help researchers and others understand the epidemiology and long-term outcomes of such brain injuries.

Public health experts first must get a better understanding of the major causes of TBIs and then implement appropriate intervention strategies, said Arlene Greenspan, DrPH, acting branch chief of the CDC's Health Systems and Trauma Systems Branch.

“There are things we know that we can do about TBIs that aren't uniformly being carried out,” she said.

Primary care doctors should expect to bear much of the responsibility for identifying and caring for such patients, because of an insufficient number of physicians who specialize in brain injuries, said neurologist Brent Masel, MD. He is president and medical director of the Transitional Learning Center in Galveston, Texas. The center cares for people with brain injuries.

“In the entire U.S., there are about 200 physicians who are fellowship-trained in brain injury,” he said. “That's not enough.”

Data show that physicians increasingly are diagnosing TBIs. Seventy-five percent of all such injuries are concussions, the CDC said.

75% of traumatic brain injuries are concussions.

In 2009, at least 2.4 million emergency department visits, hospitalizations and deaths were related to a TBI, according to the latest CDC data. ED visits for such injuries increased 14.4% between 2002 and 2006. Hospitalizations related to TBIs climbed 19.5% during the same period.

Likely contributing to the increase in diagnosed concussions is improved public awareness about the condition and better physician recognition of the symptoms, some doctors say. Other possible factors include a growing number of children who start contact sports at a young age and play year-round rather than for one season, Dr. Rempson said.

Concussion symptoms, including difficulty thinking clearly, dizziness and irritability, often resolve within a week or two, research shows. But in 20% of the cases, symptoms last for months or years, which can negatively affect people's performance in school or at work, said Robert Cantu, MD, a clinical professor of neurology and neurosurgery at Boston University School of Medicine. He is co-director of the Center for the Study of Traumatic Encephalopathy, a joint venture of Boston University School of Medicine and the Sports Legacy Institute.

“To call [this] a mild injury is very inappropriate,” Dr. Cantu said.

In an effort to address the problem, the NFL implemented multiple changes, including creation of a hotline to report when players with head injuries are forced to practice or play against medical advice. Between 2009 and 2012, at least 41 states enacted laws to address TBI, said the National Conference of State Legislatures. A majority of the legislation targeted youth sports-related concussions, while others called for funding for TBI prevention and treatment programs or required insurers to provide coverage for TBI patients.

Written OK required to play

American Medical Association policy supports requirements that young athletes suspected of having a concussion receive written approval from a physician before they return to play or practice.

A major challenge in preventing TBIs is convincing the public that concussions negatively impact health, said Jeffrey M. Mjaanes, MD, a sports medicine specialist at Rush University Medical Center in Chicago.

“We're going up against this old mentality that a concussion is just a stunned brain and not a significant problem,” said Dr. Mjaanes, director of the Chicago Sports Concussion Clinic at Rush. “Changing that mentality is huge.”

To help overcome that obstacle, he encourages physicians to speak to young athletes and their parents during sports physicals about the cause of concussions, symptoms of the injury and its negative health effects. He also recommends doctors remind athletes that if they suspect they have a concussion, they should stop engaging in the activity and seek medical treatment.

Claims that new helmets, protective padding and mouth guards prevent concussions are a concern for Dr. Rempson because he said they give parents and young athletes a false sense of security. He recommends that physicians tell patients and their families that no product can completely eliminate concussion risk.

Doctors say no person should return to play without first being cleared by a physician. “Be absolutely certain that your athlete is asymptomatic first at rest, then at full exertion before you have any thought of putting someone back into play,” Dr. Cantu said.

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External links

“CDC Grand Rounds: Reducing Severe Traumatic Brain Injury in the United States,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, July 12 (link)

“Heads up: Concussion Training for Medical Providers,” Centers for Disease Control and Prevention course (link)

CDC on traumatic brain injury: clinical diagnosis and management (link)

National Conference of State Legislatures on traumatic brain injury legislation (link)

“American Medical Society for Sports Medicine Position Statement: concussion in sport,” British Journal of Sports Medicine, January (link)

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