By Erik Brand MD MSc, Johns Hopkins University School of Medicine, and Richard Zorowitz, M.D., Johns Hopkins Bayview Medical Center
Erik Brand is a volunteer with
The severe traumatic brain injury (TBI) sustained by snowboarder Kevin Pearce while training for an Olympics qualifier gives healthcare providers, coaches and athletes an opportunity to raise awareness about common signs, symptoms, treatment, and prevention strategies in hopes of improving athlete safety.
TBI constitutes an estimated 15-20% of the 600,000 annual injuries related to skiing and snowboarding (Mueller et al., 2008). The Centers for Disease Control and Prevention (2006) estimate that 2% of the U.S. population live with some degree of disability from TBI, and approximately 80% of TBIs are “mild TBIs” (Kraus et al., 1996).
Definition and Mechanism
TBI occurs when a blow to the head causes an abrupt acceleration/deceleration of the brain that results in a variety of physical, neurological, and neuropsychological sequelae (Erlanger, 2003; Iverson, 2004; McCory et al., 2002). The World Health Organization (2004) and American Congress of Rehabilitation Medicine (1993) define mild TBI as any period of loss of consciousness, loss of memory for events immediately before or after the accident, mental status change at the time of the accident, and focal neurologic deficits. Post-traumatic amnesia typically is the most specific diagnostic feature (Ruff et al., 2006).
Mild TBIs go under-diagnosed since most people seek no care or defer medical consultation (National Institutes of Health, 1998; Kay et al., 1992: Langlois et al., 2003; Mellnick et al., 2003; Sosin et al., 1996). The National Academy of Neuropsychology (2009) reports that mild TBIs are challenging to diagnose due to a lack of consensus on definition and diagnostic criteria, lack of neuroimaging findings, and rapid resolution of acute signs and symptoms. The diagnosis of mild TBI should be based upon clinical characteristics and not neuropsychological testing alone (Ruff et al., 2009).
Athletes should not return to play until neurocognitive function returns to and remains at baseline during graded increases in non-contact sport-specific movements. Because the brain of young athletes is susceptible to more serious injury during the recovery period (Bruce et al., 1981; Kelly et al., 1997; McQuillen et al., 1988), a second blow could lead to loss of cerebrovascular autoregulation, brain swelling, and death (Cantu 1998, Kelly et al., 1997). The National Academy of Neuropsychology (2007) recommends conservative management, consisting of neuropsychological testing, reaction time, attention, memory, and speed of mental processing.
Most athletes recover completely within one month of injury (Collins et al., 2006). However, athletes with mild TBI are 4-6 times more likely to suffer a second concussion (Guskiewicz et al., 2003), and three or more concussions are associated with neurological and neuropsychological deficits and slow recovery (Gaetz et al. 2000, Iverson et al., 2004, Guskiewicz et al., 2003).
An athlete suspected of sustaining a mild TBI must be cleared by a physician before returning to play. Education for coaches, youth athletes, and parents is critical in diagnosing and treating mild TBI.
Question: Should baseline neuropsychological testing be a requirement of pre-participation physical examinations for winter and other athletes?
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