By Dr. Adam Aronson
Sports-related concussions are hot topic in recent years both in the media and for pediatricians and emergency medicine doctors. With soccer, football, hockey, lacrosse, basketball and more, so many children and adolescents participate in highly competitive contact sports, putting them at risk for head injury and a possible concussion. It is extremely important for parents, coaches, and trainers to be familiar with the signs and symptoms of concussion and to understand the importance of seeking appropriate medical evaluation and treatment. Our understanding of this common injury and its potential long term complications has changed dramatically in recent years – and it is no longer acceptable to just “tough it out.”
The signs and symptoms of concussion are variable – with some being obvious such as loss of consciousness – to less specific complaints such as feeling a bit “foggy.” Common physical changes include headache, nausea and vomiting, feeling dazed or stunned, visual changes, dizziness or balance disturbance, and sensitivities to light or sound. These are often accompanied by a host of cognitive and emotional symptoms – difficulty concentrating, being forgetful and having trouble remembering recent events, feeling confused or answering questions slowly, and generally feeling slowed down or mentally foggy. In the days and weeks after the initial injury many patients also experience irritability, anxiety or feelings of sadness. Sleep patterns can also be affected – with some individuals feeling drowsy and sleeping more than usual, while others having difficulties falling asleep.
Any child or adolescent who suffers a head or neck injury should be carefully assessed for any signs of concussion. If there are any concerning symptoms, no matter how mild – the athlete should be removed from the practice or game and should be evaluated by a physician. This evaluation can usually be done 1-2 days later by the child’s primary care pediatrician but referral to a local emergency department is indicated if the athlete experiences more severe symptoms. These would include and loss of consciousness -no matter how brief – or other change in mental status, vomiting, severe headache, dizziness, slurred speech or unusual behavior, confusion or memory loss, or weakness/numbness of an extremity. While in the emergency department the injured athlete will be assessed to determine if neuroimaging is appropriate. The test of choice is usually computed tomography, otherwise known as a CT scan. However, the majority of athletes who suffer a head or neck injury do not need to undergo this level of testing and will be managed by careful examination and monitoring.
The focus of management of a young athlete with a concussion is to educate the patient and their family regarding activities to avoid to allow the brain to recover. There are no medications that have been shown to shorten the course of symptoms, although ibuprofen is often recommended by physicians to alleviate headache. Recent studies have demonstrated that “Cognitive Rest” can hasten recovery. Children and adolescents with concussions often find that attending school, taking tests, doing homework, and even leisurely reading will worsen their symptoms. These activities should be carefully monitored and limited as much as possible to allow the brain to recover. Computers, video games, and watching TV also require focus and attention and should therefore be strongly discouraged as they may exacerbate the post concussion symptoms and prolong recovery time. fter someone injures an ankle, they instinctively know to stay off of it for some time to let it heal – the brain is no different, it needs to be allowed to rest for the concussion to heal. The importance of this “Cognitive Rest” is often overlooked, but it is a critical component of recovery.
Physical rest is also extremely important. Aside for avoiding any physical activity that might expose the athlete to further head injury – the healing brain needs energy and avoiding significant or strenuous physical exertion may hasten recovery.
Although complete prevention of sports related concussions may be impossible, many measures are being taken to lower risks. These include rule changes and improvements in protective gear such as helmets and mouth guards – though no there is limited evidence to demonstrate if these have resulted in an actual reduction in concussions. The most important part of caring for athletes with head injuries continues to be education regarding recognizing the signs of concussion and the importance of seeking proper medical attention.
One of the most important considerations is determining when it is safe to allow the athlete to return to practice and competition. Because each individual will recover at a different pace, there is no established schedule – but there are clear guidelines that must be followed. No one should ever be allowed to play on the same day. Pediatricians and families should err on the side of caution and “when in doubt – sit them out.” Young athletes should be cleared to return to play only when completely symptom free both while at rest and during exertion. Families should be warned that studies have shown that the recovery time in younger athletes is often up to 10 days longer than adults with similar head injuries – so parents and athletes must remain patient.
Parents need to remain educated and proactive so that they can ensure their children get proper diagnosis and treatment after all head and neck injuries.