Ahead of the Game

July 03, 2017 - Promise Magazine

Concussions require immediate and expert attention, and at Children’s Health new initiatives to address this serious childhood injury is getting kids back to play and playing.

By Patrick McGee

In December, 10-year-old Xavier Sanchez was knocked unconscious in a car accident and rushed to Children’s Medical Center Dallas. His mother, Adriana Angel, was deeply worried, but said she could take some solace in the fact that so many doctors were tending to him.

“I am talking about doctors everywhere,” the Dallas mom said. “They were completely prepared.”

Brittany Banks, of Waxahachie, said she had a similar experience when she took her son, Andre, to Children’s Medical Center Dallas after he fell and bumped his head when he was 5 months old. Children's did not release him until four doctors had examined him.

“Their focus was solely on him,” Mrs. Banks said. “I was just really in awe of the service. They were very thorough.”

The intense attention that these mothers witnessed is the standard of care at Children’s Health no matter the illness or injury, but particularly so when it comes to managing concussions. Careful examination is important because kids, and even parents, can be too quick to say everything’s fine, and it’s time to get back in the game.

Concussions have recently received tremendous media attention, much of it spurred by the fact that experts now have much better insights – sobering insights – into just how damaging some of these head injuries can be. And, as more and more parents, coaches and even kids themselves recognize the symptoms, hospitals are seeing a spike in concussion patients. Children’s Health experts predict that they will see more in the coming years, and they are ready with many new initiatives.

Dr. Troy Smurawa and Jeff Baggett, Children's Health Andrews Institute

Children’s Health concussion services, the Children’s Health Andrews Institute for Orthopaedics and Sports Medicine, and Children’s Health Rehabilitation and Therapy Services each have experts and new ways of assessing and treating concussions. This renewed focus on traumatic brain injury has brought Children’s Health its first postdoctoral fellow in headache and concussion, and collaboration with UT Southwestern Medical Center is accelerating concussion research on multiple fronts. The Children’s Health Andrews Institute conducts educational outreach specifically about concussions with thousands of high school coaches and athletic trainers, and it is in the process of acquiring new equipment for concussion patients and recruiting a neuropsychologist to work exclusively with these patients.

The need is great. North Texas’ young population is growing, and Texas celebrates high school football probably more than any other state.

“It’s part of the culture, part of the fabric of Texas quite honestly, and we deal with it as best we can,” said Dr. Robert Rinaldi, who, as division chief of pediatric rehabilitation medicine at Children’s Health, is expanding the number of therapists in Children’s Health Rehabilitation and Therapy Services who are trained to work with concussion patients.

“Kids need to be better taught how to tackle correctly,” he said. “I just don’t think kids are physically ready for tackle football until they’re in adolescence.”

But that cannot be mandated – at least not yet. When the junior high school tackle football team was disbanded in Marshall, Texas, two years ago, parents and students who love the sport simply splintered off to form their own league. Nothing is going to stop millions of kids from being active and pursuing sports. That’s where education comes in, and the Children’s Health Andrews Institute is taking the lead.

“I speak at several coaches groups – not just for football but for all sports – several times a week,” said Jeff Baggett, the outreach program manager at the Children’s Health Andrews Institute. He recently presented to hundreds of football coaches with USA Football in Dallas, Houston, Waco and San Antonio, and he presented to athletic trainers at a DFW Coaches Clinic in January.

Mr. Baggett said coaches seem primarily interested in how to return athletes safely to their sport, but there’s no question that almost all of them have accepted concussions as a serious issue.

Dr. Troy Smurawa (right) monitors a young teen.

“No sport is without risk. We’re working on ways to make things safer,” Mr. Baggett said, explaining that it’s not just the high-profile football games that cause concussions but also the unhelmeted sports of basketball, where players are getting elbowed in the head; lacrosse, where midfielders are getting smacked with the ball; and cheerleading where girls are smashing into the hard gym floor.

When the Children’s Health Andrews Institute opened a concussion clinic at the Children’s Health Plano campus in the fall of 2016, doctors saw about 40 concussion patients a week.

That number is expected to double this fall, according to sports medicine pediatrician Dr. Troy Smurawa.

As director of pediatric sports medicine for the Children’s Health Andrews Institute, Dr. Smurawa leads a team that treats concussion patients, along with another physician, a nurse practitioner, physical therapists and athletic trainers. They’re recruiting a neuropsychologist to join the team. A full-court press is needed to treat this growing problem, he said.

“Concussion affects the brain’s ability to function on different levels, anywhere from cognitive levels to emotional levels to balance,” Dr. Smurawa said. His description of what happens in a concussion is even more unsettling: Imagine the brain bashing up against the inside of the skull. With only spinal fluid to cushion it, the brain can even bounce inside the skull and harmfully bang up against the inner cranium more than once. If the body is jarred violently enough, as it often is in sports, the brain can twist, pulling the two hemispheres away from each other.

“Severe cognitive damage could occur. It could last from minutes to a lifetime,” Dr. Smurawa said.

The Childnren's Health Andrews Institute has special equipment to measure concussion patients’ balance, and the clinic recently purchased a cutting-edge machine with sensors that attach to the patient’s head and measure eye movements. The patient’s abilities in areas such as balance and cognition are carefully monitored as doctors try to treat symptoms like headaches and map out a plan for the student athlete to return safely to normal activities.

But concussions are not limited to only athletes. Many children suffer from damaging blows to the head because they have smaller, weaker neck muscles to cushion such a blow, according to Dr. Tonia Sabo, a UT Southwestern assistant professor of pediatrics, anesthesiology and pain management, and neurology and neurotherapeutics.

Dr. Tonia Sabo examines Devon Green.

In her role as medical director of consussin services, Dr. Sabo and her clinical team make up the Neuro-Concussion branch of the comprehensive Children’s Health Concussion Program. Her clinic sees local and statewide concussion referrals – typically the children who may not be recovering well from a concussion or who have specific neurological issues related to a mild traumatic brain injury.

Her clinic also uses state-of-the-art equipment for diagnosis and treatment of concussion. She is specifically interested in radiographic diagnosis of concussion using techniques such as functional magnetic resonance imaging and diffusion tensor imaging, and physiological diagnosis using Transcranial Doppler. Most recently, she presented a paper at the International Brain Injury Association meeting, where she detailed specific cases of post-traumatic headache that have responded to specific treatments for mildly high cerebrospinal fluid pressure.

She is a co-investigator on two currently enrolling concussion studies looking at these techniques in both high school and college-age students. She said that a patient who may be “asymptomatic” after several weeks following a concussion could still show abnormalities on Transcranial Doppler ultrasound when specifically looking at cerebrovascular reactivity. If the patient’s brain is still in a fragile state, she said, it may not be safe for that patient to resume contact sports. She received partial funding through Children’s Medical Center Foundation, which will enable her and her trainee to begin the certification process to bring this technology to the clinical setting.

It is cutting-edge technology such as this that puts Children’s Health and UT Southwestern at the forefront of concussion management and diagnosis, Dr. Sabo said.

She’s also involved in a statewide initiative for concussion reporting along with a multidisciplinary team at UT Southwestern. Board-certified in child neurology and headache medicine, she previously worked for seven years as an assistant professor of pediatrics and neurology at Colorado Children’s Hospital/University of Colorado Health Sciences Center, where she created a comprehensive headache program and treated several Olympic athletes.

“Concussions have always been around,” Dr. Sabo said. “But now we’re realizing how much these smaller injuries can add up to potentially cause significant issues, especially for a child for whom brain development and maturity is occurring. Twenty percent of athletes in high-contact sports will have some sort of concussion injury. If you get one, you are three times more likely to have another that season.”

Much education has taken place in recent years, Dr. Sabo said, with schools and athletic governing bodies realizing the importance of watching for the warning signs of a concussion: headaches, neck pain, nausea, sensitivity to light, confusion, slurring of speech and even stuttering.

Dr. Sabo works to provide families with guidance. She loves working with kids – teenagers in particular – because she believes she can make a true difference for them. “It’s very motivating to see them telling the coach, ‘I want to protect my health.’”

Last year, more than 5,000 patients were seen in the Children’s Health Emergency Department and affiliated clinics for the diagnosis of concussion or related concussion sequela. In addition to working with young athletes, Dr. Sabo also treats children who have been in accidents or experienced other trauma.

The Neuro-Concussion and Headache Clinic recently began offering yoga classes, funded by The Children’s Trust, to help concussion patients regain balance. The clinic is also where Children’s Health’s first pediatric headache and concussion fellow, Dr. Eric Remster, a pediatric neurologist, is studying specific cases of pseudotumor cerebri (which can be seen after concussion) and Transcranial Doppler. The clinic is scheduled to grow fourfold as it accommodates its growing number of patients, many of them concussion patients, and moves into the new Children’s Health Specialty Center Cityville.

One of the patients was Devon Green, a Dallas 10-year-old who suffered a concussion when he fell off a stool and hit the back of his head on the hard floor. What followed next were some of the classic signs of a concussion: He felt dizzy, couldn’t stand and vomited in the school nurse’s office. Two days later he still felt dizzy and was taken to Children’s Medical Center Dallas. The bad news was that Devon would have to sit out the rest of his pee-wee football season. The good news was that Dr. Sabo had a plan of rest that could – and did – help him reach full recovery.

His recovery was tracked by carefully monitoring important physical and cognitive abilities. A nurse took notes as she asked Devon to recite words and numbers and then recite them backwards. Then she had him stand on a wobbly mat, feet together, then one foot in front of the other, then standing on just one foot with his arms out and eyes closed. His toes griped the mat, and his eyes darted back and forth under his eyelids as he struggled to maintain his balance. He grumbled under his breath that his exclusion from his pee-wee football team cost his team the championship.

The nurse left the exam room and entered data into a huge, growing database of concussion patients that is being administered by Dr. Munro Cullum, who is chief of psychology at UT Southwestern Medical Center and holds the Pam Blumenthal Distinguished Professorship in Clinical Psychology. Dr. Cullum maintains a detailed North Texas database and a statewide database.

Children's Health's first pediatric and concussion fellow, Dr. Eric Remster

“There’s so much we don’t know,” Dr. Cullum said. “We don’t know right now who is going to be at risk for prolonged recovery from concussion, and that is a huge research area. Roughly 10 percent to 15 percent still have symptoms weeks later, sometimes months later, and we can’t identify who those are going to be yet.”

He said the growing database will be used to try to answer these questions and identify best practices.

Devon, the would-be pee-wee champ, is in the database. After the nurse typed in his test results, Dr. Sabo came into the exam room and asked him similar questions. She held his head in her hands to examine it and asked if he felt back to his old self. “Yes,” he said.

“Is that the truth?” she asked. “Because sometimes we get kids who want to go back to play, and they don’t always tell us everything.”

Devon said it was true. Dr. Sabo said all signs showed he was right.

“Does this mean I can go back to sports and stuff?” he asked.



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