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Nov 24

Concussions



Concussions:  How Concussions Cause Brain Impairment/Damage and Their Impact on Immature Teenage Brain

 

Pennsylvania’s “Safety in Youth Sports” governing all athletes who suffers a concussion goes into effect for all school districts in the state on July 1, 2012.  The new state law requires scholastic athletic programs to remove a player suspected to have sustained a concussion from play.  A concussion is classified as a minor Traumatic Brain Injury (TBI). The player is not allowed to play again until a medical professional clears them to return. 

 

In preparation for this law, the objective of this article is to begin to inform school district personnel in Traumatic Brain Injury (TBI) and concessions.

 

According to the Centers for Disease Control (CDC), there are as many as 3.8 million sports and recreation related concussions are estimated to occur in the US each year.  The CDC reports the number of TBIs in children and adolescent resulting from sports or recreation-related activities increased by 60 percent between 199 and 2009.  Emergency departments treated 173,285 children and teens up to age 19 for TBIs in 2009.

 

In Pennsylvania, there are annually roughly 22,000 children ages 0 -21 suffer concussions.  Moreover, The Brain Injury Association of PA reports approximately 4,000 Pennsylvania’s children survive severe traumatic brain injuries significantly enough to require hospitalization.  Many are left with life-altering difficulties in physical, cognitive, or behavioral functioning.

 

A concussion is a type of TBI, caused by a bump, blow, or jolt to the head that can change the way a brain normally works.  They can also occur from a blow to the body that causes the head to move rapidly back and forth.  All concussions are serious.  Eighty percent of concussions resolve during the first three weeks, but in some cases, symptoms persist for much longer, and five to ten percent last a lifetime.  Multiple concussions add up over time while symptoms tend to be worse and linger longer with each subsequent concussion.

 

Brain injury can occur even if there is no loss of consciousness and initial CT/MRI is likely to be normal.  More than 90% of conscious do not involve loss of consciousness.  Memories of events before and after the concussion are more accurate assessments of severity than loss of consciousness.  The three most commonly reported symptoms of concussions by athletes one to 7 days following a concussion are headache (75%), difficult concentrating (57%), and fatigue (52%). 

 

Persistent symptoms lasting at least three months past the injury, commonly called Post-Concussion Syndrome, are decreased processing speed, short-term memory impairment, concentration deficit, irritability/depression, fatigue/sleep disorder, a general feeling of “fogginess”, and academic difficulties.

 

Why are concussions so dangerous?  Why do they cause long-term mental problems?  Why does it take so long to fully recover from a concession?

 

Before we get to answer these questions, a little background in brain anatomy would be helpful.

 

The brain is incredibly complex and dynamic system with vast overlapping neural networks.  These neural networks give rise to everything from blood pressure, body temperature control, heart rate, emotions, and thoughts. 

 

The brain has very little internal structure.  It is the size of a grapefruit or coconut, the shape of a walnut, the color of uncooked liver, the consistency of Jell-O, chilled or soft butter or a raw hardboiled egg, and feels like an avocado.  A brain will assume the shape of a cup.

 

The body has many internal structures.  Bones, muscles, cartilage, ligaments, tendons, and skin all provided structural support.  The brain has very little of that.

 

L. Todd Rose, Harvard Graduate School of Education Faculty Member explains that given the brain’s delicate nature, and its vital importance, it is not surprising that the brain is incredibly protected in three ways.  Starting from the outside in, the first layer of protection is the skull, which serves as the outer most layers of protection and acts as amour shielding the brain from blunt trauma.

 

Just below the skull are three membranes called meninges that serve as the second layer of protection Rose continues to explain.  They do several things, but importantly they act as a buffer between the skull and the brain itself, because while the skull is a great as a shield, it is actually quite destructive if it comes in direct contact with the brain it is trying to protect.

 

The third way that the brain is protected is that it is bathed in cerebrospinal fluid.  This fluid circulates through vast cavities called ventricles that are deep inside the brain.  These ventricles both cushion the brain against blows from outside but also allow the brain to float.  Since the brain doesn’t have a lot of internal structure, the ventricles acts as a balloon that allows the cerebrum to sit and float, taking pressure off the rest of the brain that would literally collapse under its own weight without this support.  So, the ventricles play an important role in both prevention of trauma from outside, and provide some measure of internal structure.

 

A concussion is not a bruise.  It is not a strain.  Remember that the cerebrum is a Jell-O substance with no bones supporting it.  Although a cushion of cerebrospinal fluid surrounds the brain, a severe impact or abrupt change in head speed can push the three-pound of Jell-O like brain substance containing 100 billion neurons with their corresponding 100 trillion synapses straight through the fluid, crashing into the cranium.  (The brain has no pain receptors, which means the impact can only be perceived indirectly, as a throbbing headache or loss of consciousness.)

 

In the online article The Fragile Teenage Brain, Jonah Lehrer elucidates that in the milliseconds after a concussion, there is a sudden release of neurotransmitters as billions of brain cells turn themselves on at the exact same time.  This frenzy of activity leads to a surge of electricity, an unleashing of the charged ions contained within the neurons.  It’s as if the brain is pouring out its power.

 

The worst part of a concussion, however, is what happens next as all those cells frantically work to regain their equilibrium notes Lehrer.  This process takes time, although how long is impossible to predict: sometimes hours, sometimes weeks, sometime never.  (The latest guidelines suggest that most concussed subjects require at least 10 days to recover, with adolescents generally needing a few days more.)  While the brain is restoring itself, people suffer from a long list of side effects, which are intended to keep them away from thinking too hard.  Bright lights are painful; memory is fragile and full of holes; focus is impossible.

 

Lehrer emphasizes the healing has to be uninterrupted.  In the aftermath of a traumatic brain injury, the brain remains extremely fragile.  Because neurons are still starved for energy, even a minor “secondary impact” can unleash a massive molecular cascade.  All of a sudden, brain cells that seemed to regaining their balance begin committing suicide.  The end-result is a massive loss of neurons.  Nobody knows why this loss happens, but the lost is permanent.

 

Teenagers are especially susceptible to these massive cellular suicides.  This is largely because their brains are still developing and not fully developed until around the age of 25.  The younger a child is when a brain injury occurs, the more pervasive the impact the injury.  The capacities in the processes of development, and those not yet developed are those most vulnerable to brain injury, which means even a slight loss of cells can alter the trajectory of brain growth.

 

The so-called executive functioning skills, originating in the frontal lobes, are the most impacted by and after a concussion.  The frontal lobes, which are the last area of the brain to fully develop and are undergoing intense development in a teenager, are responsible for many higher cognitive functions, such as attention capacity, self-control, response inhibition, problem solving, decision-making, planning, and organization, and prioritizing.  The immaturity of these areas helps explain the immaturity of teenagers.

 

After a concussion, a student may say, “I can’t remember anything,” “I forgot what I’m doing,” “I feel like I’m going crazy,” “I’m losing everything,” “I can’t find or do my homework,” and “I can’t concentrate in class.”

 

One to two weeks of complete rest is critical after a concussion.  TBI injuries, including concussions, influence one’s ability to function at school and work.  Cognitive exertion and the added stimulation of school/work can significantly increase symptoms, even when the adolescent has begun to recover.  While it is true that an athlete must be 100% symptom-free before they are allowed to return to practice, they do not need to be 100% symptom-free to return to learning. 

 

Many times, educational accommodations are needed when a student returns to school after any of TBI injuries including concussions notes Brenda Eagan Brown, Program Coordinator, The BrainSTEPS Program.  These accommodations might be needed for symptoms of a TBI or concussion such as cognitive fatigue, drowsiness, easily distracted, sensitivity to light and noise, dizziness, vision and memory issues.  Following are accommodations suggested by Brown for the possible manifestation of a brain injury.

 

Extra time on assignments, use of word banks, not requiring copying notes, chunking of assignments that can be completed in one-half hour or less, and providing breaks before moving onto the extra assignment are possible accommodation that can be provided for a student with cognitive fatigue issues.

 

For drowsiness, a student may need to take brief in-class or out of class scheduled breaks every hour for 15 minutes while symptomatic.  In addition, an adjusted schedule to half day helps builds stamina.

 

A student who becomes easily distracted as a result of concussion, providing the student with short written instructions in a step-by-step sequence, testing in a separate, quiet environment, and moving the student’s seat to the front of the room or to a less distracting location would prove helpful.

 

Sitting in a dark corner to work in, moving away from windows and pull of blinds/shades, allowing the wearing of sunglasses/hat and the use of ear plugs, early dismissal to change classes, warning before fire drills, and no cafeteria, assemblies, shop classes, or band/chorus are accommodations for a children who is sensitive to light and noise.

 

For a student who is identified with dizziness issues as a result of a TBI injury or a concussion, have a buddy to walk with and carry their books, excusal from class a few minute would help proving additional assistance for the student.

 

Finally, a student with a resulting memory issues, the use of a tape recorder for lectures, word banks on tests to help reduce the demand on memory, and multiple-choice and open-book tests rather than short answer/essay are accommodations that might prove to be beneficial.

 

TBI was added into the Special Education Law (IDEA) in 1990 as a specific category requiring specialized instruction (Public Law 101-476,34 Code of Federal Regulations §300.7(c)(12).

 

The Pennsylvania Department of Health and the Department of Education have funded The BrainSTEPS Program implemented by the Brain Injury Association of Pennsylvania, to develop a school reentry program for students who suffer a TBI.  The program includes an observation of the student, communicate with the district and medical professionals to ensure a smooth re-entry, make educational recommendations, provide training for the school on the educational impact of the student’s brain injury, provide peer training, consult on all aspects of the student’s educational plan and make recommendations to the district team, and assist in transitioning a student from grade to grade or school to school by training new teachers.  BrainSTEPS teams monitor all referred students annually until they graduate.

 

The BrainSTEPS program can be reached at www.brainsteps.net or by phone 724.944.6542.

 

Sources

 

Jonah Lehrer, The Fragile Teenage Brain, Grantland, 1/10/2012

 

L. Todd Rose, Harvard Graduate School of Education Faculty Member in the Mind, Brain & Education Program

 

Brenda Eagan Brown, Program Coordinator, The BrainSTEPS Program: Returning to Learning Identifying & Supporting Students with Brain Injury, Brain Injury Association.  Presented at 2012 Special Education Leadership Summer Academy, July 25, 2012

 

 




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