Clinicians

Concussion in Young Athletes: Guide and Option for Parents Including Quantitative Electroencephalography (QEEG) and Guided Neurotherapy

Ronald J. Swatzyna, Ph.D., L.C.S.W., BCN, BCB, CBIST, CART, CCFC

In the last two years, media attention has grown exponentially regarding young athletes with mild traumatic brain injury (mTBI), commonly referred to as "concussion." The sport of football has a higher rate of concussion than any other sport. However, girls have higher concussion rates than boys do in similar sports such as soccer, basketball, and lacrosse (Halstead & Walter 2010). The good news is that with "cognitive rest," most young athletes are symptom free in less than two weeks. On the other hand, those with a serious concussion or multiple concussions will likely develop cognitive, physical, and emotional issues throughout their lifetime especially in cases when a second concussion occurs before the first one fully heals. Even with this new awareness, many young athletes go undiagnosed, and/or return to play too soon. These young athletes (<= 18) put themselves at severe risk for permanent neurological damage from even minor impacts because their brains are still maturing (Guskiewixz, et. al, 2004).

Conventional neuroimaging techniques, such as CT scans and MRIs, most often are normal in concussion injury. Mild to moderate concussions usually are limited to diffused axonal injury (DAI). CT scans and MRIs are not sensitive enough to detect damage to the axons. In the last decade, quantitative encephalography (QEEG) has gained acceptance as a way to assess concussion injury (Duff, 2004). QEEG topographical brain mapping identifies the location of abnormal electrical activity and disconnections between sites of the brain, therefore providing evidence of concussion that is not influenced by biased observation or self-report. QEEG-Guided Neurotherapy has been shown to be effective in significantly decreasing symptoms and restoring normal function of those with mild to moderate concussion. This paper discusses: 1) how common and dangerous it is for young concussed athletes to continuing playing concussed, 2) concussion management considerations, 3) the long-term effects of concussion, and 4) proactive steps parents should take. Lastly, this paper recommends QEEG and QEEG-guided neurotherapy for those young athletes whose symptoms persist over two weeks.

Athletes Playing with Concussions

Most athletes, especially the young, often hide or downplay their symptoms so they can continue to play. Teams can be more focused on winning than the safety of their players. Lindsey Vonn of the U.S. Ski Team is one example. On February 2, 2011, Lindsey fell, hit her head, and suffered a concussion while training for the world ski championship. There was evidence that she had not recovered from the concussion, but "the United States Ski Team appeared to hit the trifecta of concussion no-no's." They called the injury mild, blindly followed so-called concussion tests, then discounted clear signs that her injury remained. Lindsey passed repeated concussion exams, mostly measures of balance and short-term memory, administered by the U.S. Ski Team personnel. She acknowledged herself to be skiing in a fog. "My head just isn't thinking fast enough. I can't process the information fast enough, and that gets me behind on the course... I definitely am injured'" (Schwarz, NY Times 02/13/2011). Although Lindsey was not examined by a neurologist or a sports concussion expert, she passed all the neurocognitive assessments and said that she was just doing what the doctors said she could. When Lindsey finished her race placing second, her balance and concentration were so bad that she nearly fell and was so disoriented that she could not find the scoreboard.

Lindsey was lucky; participating in a competitive sport with a recently concussed brain is very dangerous due to slower processing speed, poorer coordination, and impaired cognitive functioning. As previously stated, unhealed injured brains are so fragile that even a relatively minor impact to the head can cause permanent neurological damage. If the U.S. Ski Team's medical personnel and Lindsey, a professional athlete, lack the ability to make good decisions based on obvious concussion symptoms, how can we expect our coaches, school trainers, and young athletes to do any better?

Concussion Management Considerations

The American Academy of Neurology Position Statement "Concussion Management in Sports" (AAN Policy 2010-36) stood as the "Golden Rule" since 1997. In October 2010, the AAN changed their position radically in regard to return to play recommendations. The 1997 recommendation allowed an athlete to return to play if symptom free for 15 minutes. The new recommendations require every young athlete to be removed from play and evaluated by a neurologist or doctor with special training in concussion management. The athlete also must be medically cleared to return to play.

A study by Talavage et al. (2010), of high school football players wearing special impact monitoring helmets, compared the players who showed symptoms of concussion with those who experienced equal head collisions, but showed no symptoms. Unexpectedly, 50 percent of the non-symptom control group developed symptoms hours after the event. After neurological testing, these delayed concussive symptom athletes demonstrated equal impairment to those who showed signs of concussion on site. Thus, those players with undiagnosed concussion continue to expose themselves to head collision events increasing their likelihood of more severe head trauma. Parents need to be aware that their child could have a concussion and not show symptoms until hours later.

Long-Term Effects

The majority of young athletes will recover just fine from a concussion. However, either because of poor decisions or lack of concussion symptoms at the time of impact, this article suggests that too many young athletes incur multiple concussions. The long-term effects of multiple concessions are cause for considerable concern, especially with pediatric and adolescent athletes, because their brains are still developing. A potentially deadly result of multiple concussions is second-impact syndrome (SIS). Second-impact syndrome can happen to an athlete who sustains a second concussion before the symptoms of the first have fully cleared. Although rare, SIS results in brain swelling, paralysis, and at times death. Young athletes with SIS have a severe brain injury, require immediate surgery to control the swelling, and require extensive neurocognitive rehabilitation. Many young athletes incur multiple concussions without getting SIS. However, a large number of them begin to experience many cognitive, physical and emotional problems.

The first noticeable problem for many individuals following concussion is a worsening in academic achievement. If left untreated, more problems are likely to develop slowly over time (Swatzyna, 2009). This delayed increase in symptoms is often mistaken for normal developmental difficulties in children and adolescents.

A Proactive Approach for Parents

It is critical that we protect our young athletes from concussions, which at the very least will produce long-term difficulty with learning and attention. We encourage parents to take a proactive approach with their vulnerable young athletes. This includes:

• following the American Academy of Pediatrics (AAP) recommendation to have every child take a pre-season (baseline) computerized neuropsychological testing procedure, such as the CNS-Vital Signs™ procedure or the IMPACT™ neurocognitive assessment, prior to the start of the season,
• closely observing their child for signs of delayed concussion symptoms following any impacts to the head,
• having their child evaluated by a child and adolescent neurologist when symptoms are observed after head impact,
• participating in a concussion management program by someone with specialized training in concussion management so their child can be safely returned to play,
• having their child cleared to return to play by a child and adolescent neurologist,
• providing physical and cognitive rest as long as their children show symptoms of concussion,
• if symptoms persist over two weeks, getting an EEG/QEEG for their child from a board certified neurotherapist who specializes in brain injury, and
• if postconcussive symptoms continue over several months, or in the case of multiple concussions, following the AAP recommendation to seek a neuropsychological evaluation to identify cognitive areas which may require academic accommodations.

Quantitative Electroencephalographic Topographical Brain Mapping

When your child's post-concussive symptoms continue for more than two weeks, it is likely that a more serious injury has occurred. In the last decade, QEEG technology has gained acceptance as a means to assess post-concussive syndrome. In a 2006 report by the committee on research of the American Neuropsychiatric Association, Colburn explained: "QEEG involves computer-assisted imaging and statistical analysis of the EEG for detecting abnormalities ... Perhaps most importantly, several large QEEG normative databases directly relevant to clinical psychiatry are available, and QEEG technology has advanced to the point where two systems have attained FDA approval" (p. 461). Additionally, QEEG has been found to be highly specific (96%) in identifying postconcussive syndrome (Duff, 2004). The following are examples of topographical brain maps illustrating the common concussion patterns. Figure 1 shows the focal slowing in the prefrontal cortex area that is common to a majority of sports concussions. Figure 2 represents the disconnection that occurs between sites of the brain caused by diffused axonal injury. Figure 3 identifies impaired processing speed between the concussed sites of the brain.

Figure 1: Focal slowing in absolute power of the pre-frontal cortex shown in red

Figure 2: Reduced connectivity shown as hypocoherence in blue

Figure 3: Reduced speed of information transfer shown as phase lag in red

Neurotherapy Treatment of Concussion

Neurotherapy, neurofeedback, or EEG biofeedback is: "a training system in which brain wave activity obtained by sensors on the scalp, is presented to an individual as feedback in the form of a video display or audible tone. When brain activity moves toward improved patterns of self-regulation, the display (often a video game) advances or the tone intensifies, slowing or stopping as brain activity regresses. Well-described patterns of optimal brain function are cultivated over sessions, accompanied by diminution or elimination of pathologic conditions as the brain orchestrates its own improvements. Results are at least long-lasting, often permanent, and continue to advance following training" (http://www.wordiq.com/definition/Neurofeedback).

The literature review by Duff (2004) came to the conclusion "that neurotherapy may be an effective and cost efficient method of treating patients with mild traumatic brain injury (concussion) ... The role of QEEG to help guide the neurotherapist in choosing which EEG variables and locations to target for biofeedback has been proven to be of value" (p. 205). Jonathan Walker (2007), a neurologist in Dallas states: "neurofeedback, particularly QEEG-guided neurofeedback, is a powerful tool for remediating persistent posttramatic symptoms of patients with mild or moderate head injury. It is a non-invasive, holistic, non-toxic, safe, rapid and inexpensive way to remediate the symptoms in these patients" (p. 360).

QEEG-Guided Neurotherapy uses the information from the QEEG to establish training protocols. Five sessions with each protocol normally is sufficient to correct dysfunctional problems. At the end of 40 sessions, another QEEG is required if more training is desired; however, this is not the norm.

Summary

Playing sports is a right of passage for so many of our children and concussion prone sports are likely to be around for decades to come. However, in spite of the efforts to make sports safer, too many of our children will be concussed and develop long-term cognitive, physical or emotional issues. This article provides information parents need to keep their children safe and help reduce or eliminate the consequences of concussion.

References

American Academy of Neurology (1997). Practice parameter: The management of concussion in sports, Neurology, 48(3), 581-585.

American Academy of Neurology (2010). Position statement on sports concussion. AAN Sports Neurology Section, Practice Committee, and Board of Directors October 2010 (AAN Policy 2010-36).

Coburn, K.L., Lauterbach, E.C., Boutros, N.N., Black, K.J., Arciniegas, D.B. & Coffey, C.E. (2006). The value of quantitative electroencephalography in clinical psychiatry: A report by the committee on research of the American Neuropsychiatric Association. The Journal of Neuropsychiatry and Clinical Neurosciences, 18(4), 460-500.

Duff, J. (2004). The usefulness of quantitative EEG and neurotherapy in assessment and treatment of post-concussion syndrome. Clinical EEG and Neuroscience, 35(4), 198-209.

Halstead, M.E. & Walter, K.D. (2010). Clinical report sport-related concussion in children and adolescents. Pediatrics, 126(3), 597-615.

Talavage, T.M., Nauman, E.A., Breedlove, E.L., Yoruk, U., Dye, A.E., Morigaki, K., Feuer, H., Leverenz, L.J. (2010, October 1). Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion. Journal of Neurotrauma. [Epub ahead of print.] PMID: 20883154.

Schwartz, A. (2011, February 13). Concussion protocols fail Vonn. New York Times, p. D1.

Swatzyna, R.J. (2009). The elusive nature of mild traumatic brain injury. Biofeedback, 37 (3), 92-95.

Walker, J.E. (2007). A neurologist's experience with QEEG-guided neurofeedback following brain injury. In J. R. Evans (Ed.), Handbood of neurofeedback (pp. 353-361). Binghampton, NY: Haworth Press. doi:10.1300/5889_15.