Understanding the Long-Term Effects of Concussions in Adolescents
One in five children in the U.S. will suffer a concussion by age 16, most often caused by falls, sports injuries, and motor-vehicle accidents. Dr. Karin Reuter-Rice, PhD, CPNP-AC, FCCM, FAAN, associate professor of nursing and pediatrics, is conducting a 5-year study exploring the long-term effects of concussions in adolescents.
"Research on concussions in adolescents has generally focused on the days and weeks immediately following the injury," Reuter-Rice said. "Little is known beyond the acute stage." Importantly, there are underexplored symptoms such as persistent fatigue, which more than 73% of patients with concussions complain, or biological markers associated with symptoms that have yet to be fully identified within the context of longer-term effects concussions have on academic and social outcomes.
Research shows that adolescents who experience concussions have worse symptoms than their adult counterparts, and their symptoms last longer. Clinical care is complicated because post-concussion symptoms (PCS) vary considerably among adolescents, with at least 25% still experiencing symptoms a year after the injury. Additionally, adolescents who suffer concussions can become asymptomatic within a few weeks after the injury but report academic and social challenges months later.
"Unlike a broken arm, a concussion is an invisible injury; there is no obvious cast to indicate the brain has been injured," Reuter-Rice said. "This translates into others assuming the adolescent is fine, when in fact they could be suffering from post-concussion symptoms that affect their academic success and social interactions."
Sports-related injuries cause the bulk of concussions among adolescents, with boys' tackle football and girls' soccer having the highest rates of concussion in the U.S., according to the Centers for Disease Control. In North Carolina, the State Board of Education Policy requires schools to implement a strict return-to-learn plan for addressing the needs of all students of all ages who might suffer a concussion, regardless of the cause. The plan must include guidelines for the removal of students from physical or mental activity if a concussion is suspected. Staff and parents must be notified, and plans must be made for medical care updates and student accommodations. Requirements for return-to-learn and return-to-play must be outlined and followed.
"Early recognition of a concussion is paramount," Reuter-Rice said, "so having trained personnel such as athletic trainers and school nurses in each school is a first step." Headaches, dizziness, blurry vision, sensitivity to light, tiredness, and difficulties with thinking and functioning are the most common acute symptoms following a concussion. But factors such as socioeconomic status, ethnicity, gender, language barriers, or lack of access to healthcare can create barriers to health equity with some adolescents not receiving the care they need. "Concussion management requires a team approach, which includes the adolescent, family, school, and healthcare professionals," Reuter-Rice said.
"While we know early intervention can improve health, academic, and psychological outcomes in adolescents diagnosed with a concussion, we lack evidence-based methods for predicting which adolescents are at greater risk for ongoing symptoms or problems after a concussion," Reuter-Rice said. "Our research aims to identify a new approach that allows for the earlier identification of adolescents who will experience persistent post-concussion symptoms so that tailored precision health approaches can be developed and initiated sooner after injury, thereby improving outcomes."
Study participants are children between the ages of 11 and 17 who have experienced a concussion, also known as mild traumatic brain injury, and who agree to six visits over 12 months after the injury, where they give interviews and saliva samples. Interviews include questions about fatigue, peer relationships, ability to think and function, and concussion support that is available to them in school. The retention rate in the first year of the study was 93% and remains equally high in year two, Reuter-Rice said, indicating that sharing the experience of having a concussion is of importance to adolescents and their families.
The study, titled, A Risk Stratification Model for Health and Academic Outcomes in Children with Concussion Based on Novel Symptom Trajectory Typologies also known as the RSiCC study, aims to develop a risk model that sets the framework for future intervention trials and the development of new targeted therapies. Rice’s initial findings were published in the journal PLoS One this past July. This research is a critical first step in developing personalized concussion symptom management that can influence healthcare delivery, improve quality of life, and reduce the substantial health and socioeconomic burdens of concussions for children, adolescents, families, schools, and healthcare.