By BILL PENNINGTON
BOSTON — The drumbeat of alarming stories linking concussions among football players and other athletes to brain disease has led to a new and mushrooming American phenomenon: the specialized youth sports concussion clinic, which one day may be as common as a mall at the edge of town.
In the last three years, dozens of youth concussion clinics have opened in nearly 35 states — outpatient centers often connected to large hospitals that are now filled with young athletes complaining of headaches, amnesia, dizziness or problems concentrating. The proliferation of clinics, however, comes at a time when there is still no agreed-upon, established formula for treating the injuries.
“It is inexact, a science in its infancy,” said Dr. Michael O’Brien of the sports concussion clinic at Boston Children’s Hospital. “We know much more than we once did, but there are lots of layers we still need to figure out.”
Deep concern among parents about the effects of concussions is colliding with the imprecise understanding of the injury. To families whose anxiety has been stoked by reports of former N.F.L. players with degenerative brain disease, the new facilities are seen as the most expert care available. That has parents parading to the clinic waiting rooms.
The trend is playing out vividly in Boston, where the phone hardly stops ringing at the youth sports concussion clinic at Massachusetts General Hospital.
About three miles away, at Boston Children’s Hospital, patient visits per month to its sports concussion clinic have increased more than fifteen fold in the last five years, to 400 from 25. The clinic, which once consisted of two consultation rooms, now employs nine doctors at four locations and operates six days a week.
“It used to be a completely different scene, with a child’s father walking in reluctantly to tell us, ‘He’s fine; this concussion stuff is nonsense,’ ” said Dr. William Meehan, a clinic co-founder. “It’s totally the opposite now. A kid has one concussion, and the parents are very worried about how he’ll be functioning at 50 years old.”
Doctors nationwide say the new focus on the dangers of concussions is long overdue. Concerned parents are properly seeking better care, which has saved and improved lives. But a confluence of outside forces has also spawned a mania of sorts that has turned the once-ignored concussion into the paramount medical fear of young athletes across the country.
Most prominent have been news media reports about scores of relatively young former professional athletes reporting serious cognitive problems and other later-life illnesses. Several ex-N.F.L. players who have committed suicide, most notably Junior Seau, a former San Diego Chargers and New England Patriots star, have been found posthumously to have had a degenerative brain disease linked to repeated head trauma.
State legislatures have commanded the attention of families as well, with 43 states passing laws requiring school-age athletes who have sustained a concussion to have written authorization from a medical professional, often one trained in concussion management, before they can return to their sport.
Dr. Rebekah Mannix, an emergency room physician and a concussion researcher at Boston Children’s Hospital, works at the front lines of the new world of youth concussion management. Mannix had a concussion while playing college rugby in 1989. After visiting a nearby hospital emergency room, she recalled, she received little guidance about what to expect next — and there was no specialized center to visit if typical concussion symptoms like a headache, nausea, amnesia, fogginess or dizziness persisted.
Nearly 25 years later, much is still unknown about the roughly four million concussions diagnosed annually in America (millions may go undiagnosed). And even with the increased attention to the injury, modern concussion treatment has become a mix of practices derived from prevailing wisdom and experience, limited clinical science and common sense.
“Head injury in general is a strangely archaic field,” Mannix said. “There is no predictability. I cannot say to patient A, ‘You are going to be fine in a week.’ I cannot say to a patient B, ‘You are going to be really sick for three months.’ ”
There is no test or procedure, for example, to verify whether a patient has had a concussion. It is a diagnosis based on a doctor’s examination, observation of symptoms and understanding of the incident that led to the injury.
Brain scans can look for bleeding, but they do not identify a concussion, and they come with risks.
Talking parents out of unnecessary brain scans and repeatedly informing them that a high percentage of concussions will not cause lingering symptoms may be the best medicine given by concussion doctors. They say it is the best way to assuage the panic they hear in the voices of parents and patients.
Dr. Cynthia Stein at the Boston Children’s clinic. Among the things Stein routinely explains to patients is that pro football players like Junior Seau may have taken thousands of hits to the head in youth leagues, high school and college — in addition to 10 or more years in the N.F.L. It’s not an appropriate comparison. Our patients, if their concussions are managed properly, are going to heal on their own. The body knows how to take care of itself.”
But complicating the care is the belief that the recovery time for younger concussion patients will be longer.
“A concussion might be the only injury where the younger you are, the longer it takes to get better,” Stein said.
But there is no wall chart or medical textbook that says just how much rest or inactivity...
The lack of guidelines frustrates athletes and their parents, and can confound doctors. In this setting, determining when a young athlete is ready to return to a contact sport, or to school for the mental rigor of regular class work, becomes a highly nuanced, open-ended calculation.
In keeping with its scientifically indefinite nature, concussion management has few collectively recognized, widely acknowledged tenets. But if there is one that is accepted with only a modicum of enduring debate, it is the understanding that athletes who have had a concussion go through a period shortly after the injury during which they are especially vulnerable to catastrophic injury if subjected to another blow to the head. In the worst case, known as second-impact syndrome, it can be a fatal combination.
The chief goal of youth concussion clinics, and the chief purpose of the widespread concussion-related state legislation, is to protect those susceptible to repeat concussions in this period of vulnerability. But no one knows just how long or short that period is.
One of the most commonly known treatment protocols is cognitive rest, which often means avoiding mental stimulation like video games, television or situations with bright lights or loud noises for an extended period after the injury. It is sometimes referred to as the “two weeks lying in a cool, dark room” therapy. Like so many things in concussion management, it has been supported by anecdotal case studies but is unverified by standardized clinical trials.
At the clinics in Boston and at others nationwide, determining how much activity and stimulation are appropriate, and how soon to introduce them after a concussion, is now done on a case-by-case basis.
There is evidence that certain step-by-step treatment schedules have been successful, but therapies considered standard two years ago — like two weeks in a cool, dark room — are being challenged.
Inside the Boston clinics, in consult, a team of neurologists, sports medicine and rehabilitation specialists, physical therapists, psychologists and psychiatrists may determine a recommended course for a single patient.
The nationwide proliferation of youth sports clinics is a reaction to a health care demand. But are the clinics also profit centers?
Meehan, of Boston Children’s Hospital, responded similarly, saying that if the clinic was good for business, it was principally because of the good will it brought the institution.
Interviews with directors of youth concussion clinics nationwide produced a consensus that the clinics were not significant moneymakers because they were not procedure driven, meaning that they do not typically lead to expensive imaging tests or operations. Instead, they tie up doctors in lengthy, multifaceted patient consultations.
Most clinic patients go to the clinics because they are referred by their pediatricians, their primary care physicians or the doctors attending to them during an emergency room visit. Emergency room visits by children and adolescents with brain injuries have increased by more than 60 percent in the past eight years, according to the federal Centers for Disease Control and Prevention.
Some concussion specialists working at clinics said they believed the facilities would be more prevalent in 5 or 10 years, with a clinic perhaps located near every medium-size city in the country.
If the widespread anxiety about concussions is diminished in time, if the frenzy that doctors describe abates, there could be other outcomes as well, like a better understanding that a concussion in a school-age athlete is not necessarily a pathway to the kind of dementia found in some aging N.F.L. players.
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Source: http://www.nytimes.com/2013/05/06/sports/concussion-fears-lead-to-growth-in-specialized-clinics-for-young-athletes.html?src=recg
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