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CMP Program Development Guide
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Research has found that teenagers who suffer sports-related brain trauma have more widespread injury and prolonged brain swelling than adults. This may be related to the fact that the developing brain in a teenager has double the number of neural connections than an adult, so an injury will impact a much larger region of the brain. We also know that the immature brain is approximately 60 times more sensitive to the chemical substances that are produced following an injury. Therefore, many experts feel that high-school athletes might be expected to have a slower recovery than older adults and to be more susceptible to severe neurological deficits should they be re-injured during recovery. Because of the sensitivity to the chemical changes following an injury, coupled with the inadequate blood flow to help with the repair process, complete rest is required to prevent further damage.

On the other hand, some experts argue that teenage student-athletes should have a greater potential for recovery after concussion because of their greater potential for reorganization of the neural connections in the brain compared with adults. The fact that the developing brain has double the neural connections than an adult means that with so many excess connections this allows for neural rerouting during the recovery period. It means that if the usual communication pathway has been damaged or blocked because of a concussion, the brain may be more easily able to find another route to restore the communication to normal functionality. This leads some experts to conclude that this functional plasticity may in fact mean that teenage athletes never recover from their original injury, but that their actually reacquire near normal functionality because of the reorganization of the communication network through new pathways that are closely related to the original. In other words, the teenage brain either discovers a new way of accomplishing approximately the same results. What is not completely understood is whether or not the reorganization and rerouting can ever accomplish the same results because of the widespread impact of the original injury on so many other regions of the brain.

Therefore, the general consensus that teenagers take longer to recover from brain injuries may simply be due to the fact that teenagers who don’t allow sufficient time for the original injury to heal may in fact never recover from their injury, but rather they may develop new connections that may give them almost the same functionality as they had pre-injury. This means that it is even more critical that student-athletes take more time to ensure that their concussion has had enough time to heal so that they do not end up generating a rerouting or reorganization that may be life-altering.

The most popular treatment of concussion is simply to rest the brain by ceasing all non-essential physical and cognitive activities. This is still a wise course of action take initially, but it is becoming apparent from some studies and reports that student-athletes who still have symptoms after a few days may be more at risk for prolonged recovery if they remain at complete rest.

The carefully controlled and steady introduction of everyday stimulation shortly after an injury seems to help the brain rehabilitate as it rebuilds its ability to handle the stimulation of a normal environment. The key here is to make sure that there are adjustments put in place to help the student-athlete gradually ease back into a normal routine. You must not over-stimulate and risk the return of symptoms. 

This is why we recommend light exercising such as walking and a return to school with very specific accommodations for the student-athlete. Over time the symptoms will resolve and the brain will rebuild if you increase the stimulation gradually and steadily without reactivating symptoms.

Dr. Mukherjee is using advanced imaging techniques with patients who have suffered a concussion. He is scanning their brain right after the injury, a couple of weeks later, a month later, then a year later and has found some interesting results. For example, he has found some patients with bruises on the brain which affect the cortex, or the gray matter, which is consistent with the functional injuries that the brain has undergone. He has also found small hemorrhages within the white matter of the brain which indicate that there has been some structural injury.

He has found evidence that early after an injury the areas of the brain that are responsible for memory and attention are different and less active from what one would find in a normal person. But then he finds that six months to a year after the injury, those very same areas may become more active and in fact, hyperactive compared to a normal person.

This has lead him to conclude that there are some definite changes that occur in the brain after a concussion. He is continuing with his research to see if he might be able to discover more about the underlying science of how the brain works and what really happens when the networks in the brain are disrupted by a concussion.

While the research being done by Dr. Mukherjee may not answer all of our questions about concussions, it may shed some light on how to treat student-athletes who suffer from prolonged post-concussion symptoms.

When a student-athlete suffers a concussion, we never know what part of the brain is going to be affected by the injury. As you see from Training Module #2, Understanding The Brain, there are almost 1000 trillion connections made among 100 billion brain cells through over 160,000 km of axons. Therefore, an injury to one part of the brain may have significant affect on another.

The following two (2) video links were found on You Tube and provides some insight into just how the different parts of the brain may be affected. You will also find many other video clips that discuss concussions when you links below.

http://www.youtube.com/watch?v=T0WBMM7WKL4&feature=related

http://www.youtube.com/watch?v=wlYiDxNcMdc&feature=related

This 3D medical animation shows and explains the mechanism for mild traumatic brain injury, which includes concussion injuries. Two types of coup-contrecoup injury are shown: low-speed coup-countrecoup injury, and high-speed coup-contrecoup injury. The high-speed coup-contrecoup injury creates apparent contusions. The low-speed coup-contrecoup injury has damage from shifting layers within the brain at the microscopic level. This animation shows axonal-shearing or how axons rip away from the cell bodies of neurons during coup-contrecoup, and the degenerative damage that occurs later.

This is an excellent video for people who would like to better understand what exactly happens inside the brain when a concussion occurs.

http://www.youtube.com/watch?v=55u5Ivx31og&feature=related

Experts agree that if a person returns to physical activity too soon after suffering from a concussion, there is great risk of experiencing a second concussion that may have life-altering, long-term consequences. Furthermore, the second concussion may be caused by a force that is much less than that which caused the first concussion.

The following short video clip shows Sidney Crosby's two famous injuries in January 2011. You will note that the first blow to the head looked as if it would kill him. However, he finished off that game and began the next game, four days later. The check he received in that second game looked like nothing compared to the first check to the head received. Nevertheless, the injury he suffered from the first check to the head had obviously not healed, so all it took to put Sidney Crosby out for almost a full year was that second body check.

This is a perfect example of how easy it is to be re-injured if you return to play too soon.

This is an indication of how many concussions go unreported without the program. Student-athletes who are under the CMP Concussion Management Program will not likely be able to hide their symptoms and with so many partners on the look-out for signs of concussion, it means that you will be able to provide a much higher degree of protection against serious injuries that can result from receiving a second concussion while still recovering from the first.

Many experts indicate that there will never be a way of finding the exact number of injuries that take place, but the closer we look the more we will find. This means that as coaches, parents and student-athletes themselves are better educated on how to spot signs and symptoms of concussion, the numbers are bound to increase.

This could lead to some implications with respect to the availability of medical professionals who are first of all experienced in dealing with concussions and who also have the time to squeeze new patients into their already full schedule.

The article points out that 8 members of the 20-member Canadian Women's Water Polo Team have suffered concussions while preparing for the 2012 summer games. Head Coach, Pat Oaten stated that the increased awareness generated by Sidney Crosby has resulted in far more concussions being reported than ever before.

In particular, players are becoming more fearful about the consequences of repeated concussions and are willing to report injuries right away so that the proper management protocols can be established. Some who have tried to "tough it out" have found that by doing so they are suffering more concussions that take much longer to heal.

One of the disturbing observations made by the head coach is that he doubts that as the team gets closer to the Olympic trials any of his players will admit to a concussion in order to continue to play the game. Even some of the players have indicated that they would not let a concussion hold them back from a chance to compete in the Olympics.

This is something that parents and coaches of student-athletes at the secondary school level must be aware of when it comes to identifying possible concussions. If Olympic athletes are willing to put their life at risk just to compete in an Olympic games, then keep in mind that to a high school student, the chance to play for a city championship is his/her Olympic moment. 

Our goal is to make sure that student-athletes understand the risk and will come forward to self admit concussion symptoms regardless of when it occurs in the season.

The Province of Ontario introduced Bill 39 on March 6, 2012. A review of that legislation can be found at the following link:

Bill 39 Review

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