By Sadie R. Morway, Zachary K. Winkelmann @zachwinkelmann, Kenneth E. Games @GamesKenneth

It is crucial to examine the long-term effects following a traumatic brain injury (TBI) in sports medicine. This is especially important for children given the sensitive development of the brain during childhood and the after-effects of TBI on mental wellness and ultimately quality of life.^1-2 Understanding the potential long-term detriments is vital as youth transition to adulthood, and as we examine the possible contributing factors of behavioural health concerns related to TBI.^1-3

Scope of TBI

The scope of brain trauma ranges from mild traumatic (mTBI) to TBI with sport-related concussions (SRC) being the most common type of TBI with roughly 300,000 SRCs occurring annually in the United States.^1-2 The consideration of injury to the brain by way of SRC remains a consistent link in altered behaviour.^3-4 The purpose of this digest is to note the parallel between brain injury and adverse mental and behavioural outcomes in adolescents following an incident. The long-term health and quality of life outcomes following a brain injury are critical to improving health care recognition, management, and collaboration following injury, which ultimately can assist clinicians in providing a holistic model of patient-centered care for life after sport participation.^1-3

Externalising and internalising behaviours

A negative behavioural outcome is defined as post-traumatic clinical symptoms with deficits categorised as ‘externalizing’ or ‘internalizing’ behaviours.^1,3 Externalising behaviour is the expression of negative conduct such as aggression, substance abuse, attention-deficits, disruptive behaviours, impaired self-regulation, and suicide attempt/suicide.^1,3 These negative behaviours potentially risk the wellness of the pediatric patient as they transition into society as an adult.^1-3Internalising symptoms present more inwardly and include aspects such as depression,  personality change, apathy, anxiety, post-traumatic stress, and obsession.^1,3Likewise these factors, although internal, can deeply effect the mental wellness of an individual potentially leading to more severe externalising behaviours such as substance abuse or suicide attempt/suicide.^1-5Personality change was reported most commonly among children, often manifesting within the first 3 months following a TBI.^{1, 3, 4} Psychiatric symptoms such as aggression, risk-behaviour, cognitive impairment, and depression were common side-effects which can present immediately and/or several years later.^1,3,4  Regardless of the severity, 62% of adolescents that suffered a TBI had at least one negative behavioural issue one year after incident, and often these disorders worsened at follow-up five years post-incident.^3,5 The detection of detriments is crucial not only at the onset of the TBI, but throughout the continuum of the pediatric patient’s life whether that be through school, sport, work, or life.

Prevalence of behavioural deficits following a TBI

The literature supports a higher prevalence of behavioural deficits following a TBI compared to the healthy, general population.^1,3Additionally, post-injury patients have an increased overall risk for repeated trauma and lingering negative complications.^3-5Although the main signs and symptoms of a TBI, specifically a SRC, often dissipate to the point of clinical recovery within several weeks after injury, the long-term behavioural effects of childhood head trauma are misunderstood.^1,4,5These effects may not present themselves until later in life, perhaps effecting the quality of life well into adulthood.^1,2,4,5As healthcare providers in sports medicine, we must continue to evolve our practice regarding mental and behavioural health by exploring all aspects of the patient including a previous history of TBI and how these are affecting the patient’s quality of life, in order to provide better treatment and proper referral.

The need to measure mental and behavioural health at baseline and following TBI

While the parallel between TBI and behavioural alterations exist, there are some limitations worth noting in the literature. The baseline, or pre-injury, data for adolescents is often collected using recall by a parent or guardian which leaves room for under reporting and variability in baseline accuracy.¹ From the studies included in the review, several behavioural measures were used that could be incorporated into athletic training clinical practice to ensure baseline data is reflective of the lived experience of the pediatric patient. Tools such as the Attention-Deficit Hyperactivity Disorder (ADHD) Rating Scale, the Child Behaviour Checklist, and the Neuropsychiatric Rating Schedule may be beneficial within a holistic patient-centered model. Additionally, other validated instruments that may be useful in screening for mental and behavioural health at baseline and following TBI include the Patient Health Questionnaire and the Mood Disorder Questionnaire.⁶The integration of these patient-reported outcomes will assist in meeting the needs of the patient over time, as well as collecting necessary data relevant to athletes to ensure the health and safety of adolescent sport participation. Although the long-term effects regarding this connection remain largely misunderstood, the information can be highly useful in the recognition of behaviour deficits.^1,3 The identification of negative outcomes can assist healthcare professionals in holistic and patient-centered care by way of specialized treatment protocols.^1,3

To alter the negative outcomes following a TBI, a collaborative healthcare network using validated instruments over time is essential to achieve patient-centered care.^1-3

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Sadie R. Morway is a first year student in the clinical Doctor of Athletic Training program (@isuathltraining) at Indiana State University in Terre Haute, Indiana. She practices as an athletic trainer while also serving as an owner and co-founder of Valkyr – an Athletic Training based small business in Grand Rapids, Michigan. Sadie’s interest include exploring how sports medicine providers can seek to provide holistic, whole-person healthcare to their patients. E-mail: smorway@sycamores.indstate.edu

Zachary K. Winkelmann @zachwinkelmann is a PhD Candidate at Indiana State University in Terre Haute, Indiana, United States of America.  He currently serves as a teaching and research doctoral fellow in athletic training.  Zachary’s research interests include athletic training education, healthcare administration, and patient-centered care through the use of technology such as telemedicine. E-mail: zwinkelmann@indstate.edu

Dr. Kenneth Games @GamesKenneth / @KentGames (Instagram) is an Associate Professor at Indiana State University in Terre Haute Indiana.  He currently serves as the Director of Clinical Education for the Doctor of Athletic Training Program and is the Director of the Tactical Athlete Research and Education Center at Indiana State.  Dr. Games’ interests include injury prevention and wellness protection in tactical athletes and leadership development in healthcare providers. Email: Kenneth.Games@indstate.edu.

Competing interests

None declared

References

1. Li L, Liu J. The effect of pediatric traumatic brain injury on behavioral outcomes: a systematic review. Dev Med ChildNeurol. 2013; 55(1): 37-45.
2. Roiger T, Cover R, Zwart MB. The lived experience of retired college athletes with a history of 1 or more concussions.J Athl Train. 2018; 53(7):646-656.
3. Stefan A, Mathe JF, SOFMER group. What are the disruptive symptoms of behavioral disorders after traumatic brain injury? A systematic review leading to recommendations for good practices. Ann Phys Rehabil Med. 2016; 59:5-17.
4. Manley G, Gardner AJ, Schneider KJ, et al. A systematic review of potential long-term effects of sport-related concussion. Br J SportsMed.2017;51:969-977.
5. Iverson GL, Gardner AJ, Terry DP, et al. Predictors of clinical recovery from concussion: a systematic review. Br J SportsMed. 2017; 51:941-948.
6. Sudano LE, Miles CM. Mental Health Services in NCAA Division I Athletics: A Survey of Head ATCs. Sports Health. 2017;9(3):262-267.