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Sports Concussion in Children

2011 May 19

Sports-related concussions in children have received a lot of media coverage on the past few years. The understanding of the cause, diagnosis and management, and prevention of sports-related in concussions in children continues to evolve and it may be difficult to keep track of the new research. Here is my quick guide for kids, parents, coaches, and anyone taking care of the young athlete.

What is a concussion?

A concussion is defined as a mild traumatic brain injury that results from a direct or indirect trauma to the brain which causes cognitive and/or behavioral impairment, but no apparent structural changes. This is caused by direct or rotational forces from a blow to the head or indirect forces transmitted to the head from a hit to the body. The most common sports involved are “collision” sports such as american football, ice hockey, boxing, and rugby. Other sports in which concussions can commonly occur include “contact” sports such as basketball, lacrosse, soccer, and wrestling.

What are the symptoms of a concussion?

Common symptoms include loss of consciousness, amnesia, headache, dizziness at the time of injury. These symptoms and new ones, such as light and noise sensitivity, confusion, changes in behavior, emotional lability, difficulty concentrating or remembering, and difficulty sleeping can persist afterward. The symptoms typically improve within 7-10 days in about 90% of kids, but it is not out of the ordinary for symptoms to last 2 weeks or longer. The severity and the duration of symptoms are related to a number for factors including: force of impact, age of child, number of previous conconcussions, whether the child was still recovering from a recent head injury, other underlying medical issues. It is generally known that younger children and those with history of prior concussions can take a longer time to recover. For concussive symptoms that last longer than 2 weeks, it is advised that the athlete be evaluated by a physician who specializes in concussions.

What should I do if my child has a concussion?

Children who suffers a head injury should be evaluated by a trained professional. If a concussion is suspected, he/she should taken out of the current sporting event. He/she should be evaluated and cleared by a physician before returning to play. Generally, the child will not return to play that same day, and should be kept out of sports for at least a week. The dangers of allowing a child to continue playing include the risk of worsening symptoms, prolonged symptoms, and further injury. There is also a risk of second impact syndrome if the child incurs another traumatic blow. This can lead to significant morbidity even death.
In the first week after a concussion or if a concussion is suspected, the best thing for a child is cognitive and physical rest. This can include, but is exclusive to rest from all exertional physical activity such as their sport, running, and jumping. Taking time off from work and school can also be beneficial since cognitive exertion such as being in class, note-taking, exams, and homework can exacerbate symptoms. Lastly and just as important, activities such as video games, movie theaters, sporting events, and loud music should be avoided as these can also worsen and prolong symptoms. Parents should promote continued healthy eating and adequate hydration during recovery, as energy consumption during brain recovery can be increased. Children may sleep more, and this is both okay and encouraged for brain recovery.

When can my child return to sports?
As symptoms resolve, a reintroduction to school and sports should be directed based on symptoms. It is possible to see a worsening of symptoms if too much activity is introduced too soon. A typical return to sport progression follows six steps*:
1. Complete rest from physical activity until resolution of symptoms.
2. Light aerobic activity such as walking or stationary bike.
3. Sport specific aerobic activity such as running, ice skating, swimming, or cycling.
4. Non-contact sport-specific training drills and progressive resistance training.
5. Full-contact training, after medical clearance
6. Return to full contact games.

*Each step should be well tolerated without return or worsening of symptoms for 2-3 days before progressing to the next step. If symptoms do return, drop down a step until symptoms resolve.

Are there addition tests that need to be performed?
In a small percentage of children with concussions, symptoms can last for a month or longer. These children should be evaluated by a concussion specialist. In these situations, a detailed neurologic exam, brain MRI, neuropsychiatric testing, balance testing, and other methods may be used to evaluate the child. Diagnosis and management can be assisted with baseline neuropsychiatric testing. Many schools and sporting organizations are now requiring baseline computerized neuropsychiatric testing prior to starting collision sports. There are a few companies out there that offer this. The one that I use, and am most familiar with, is ImPACT. Medications are also available to help with symptoms of headaches, insomnia, mood changes, and difficulty concentrating.

Can I do anything to prevent this from happening again?
Prevention and early recognition of symptoms is important, and education of all those involved is the key. Coaches, parents and players should be educated about the appropriate and correct use of sport-specific protective equipment, and age-appropriate rules of their sport. Currently, there are no football or ice hockey helmuts that have been shown to prevent or decrease the risk of concussions. There are also no soccer headgear that have been shown to decrease concussions, despite what companies may say. A good strength conditioning program that focuses on cervical neck, and core strength may help in decreasing risk, but that also has not been scientifically proven. Appropriate sport-specific, and age-specific rules can help decrease the incidence.

Overall, there is an inherent risk of head injury in specific sports, and the risk of concussions can not be eliminated, but the awareness of this problem can make playing sports safer for our kids.

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