Concussions are the mildest and most common form of traumatic brain injury (TBI). They account for 144,000 emergency department visits for children annually. School aged children suffer from post concussive symptoms longer than adults an college age students. Other causes of concussions include falls and car accidents. An estimated 20% of high school football players suffer a concussion and research shows the developing brains of adolescents are more vulnerable than adults and take longer for post-concussion symptoms to resolve. The most important fact to remember is that even mild brain injuries can be more serious then they seem.
Concussions can be hard to diagnose since many adolescent athletes do not want to report the symptoms associated with such an injury. They are fearful of being removed from an activity they enjoy participating in and feel they are “letting their team and coach down” if they acknowledge the injury. The injury is a metabolic or functional alteration in how the brain works and diagnostic tools such as a CAT scan or MRI do not show the disturbance.
Cognitive testing and a thorough history and physical examination are essential for the diagnosis. Protocols to evaluate and treat concussions are usually followed with excellent long term success. Computerized and individual cognitive testing is often performed if medically indicated. Supportive counseling is also integrated into a treatment regimen if the child’s behavior or emotional response requires specific intervention.
The most common physical findings include headache, nausea, vomiting, balance problems, dizziness, visual problems, fatigue, noise and light sensitivity and possible numbness or tingling. Cognitive changes include psychomotor delays and regulatory function disturbances. Children complain of feeling slowed down in their thinking or having trouble concentrating. General difficulty with persistence, planning and attention are often seen as well as delays in inhibitory control and attention shifting. Emotional complaints include sadness, irritability nervousness and increased emotionality. Sleep disturbances are common with drowsiness often reported and sleeping more or less than usual. Sleep latency difficulty described as difficulty falling asleep is also common. All children react differently to head bumps. Those who have a concussion and have not had full resolution of signs and symptoms are at greatest risk for re-injury and more serious symptoms.
The first step in any evaluation is an on-site evaluation at the location where the child received the injury. This may involve a coach, trainer or medical support staff who have been trained in and completed concussion certification courses. The next step would be an emergency facility and then referral for follow-up care to their pediatrician. No child should leave an emergency department and return to practice that day and they should only be cleared to return to play or practice after they have received written approval from a physician.
A return to play protocol is followed. The child should have complete physical and cognitive rest and should not experience any concussion symptoms for a minimum of 24 hours. In general, the younger the child the more conservative the treatment. The following step protocol should be followed. The child or adolescent only moves on to the next step if they have been free of any symptoms for a minimum of one day to one week. Step duration must be determined on a case by case basis. When in doubt always error on the side of longer duration. Computerized cognitive testing can also be followed using the same criteria. If any symptoms return or computerized cognitive testing shows a decrease in function then the activity should be stopped immediately and additional rest obtained for a minimum of 24 hours. Thereafter, the child or adolescent should resume activity at the step prior to the one during which the symptoms were experienced. If no symptoms are experienced for 24 hours then step progression can restart.
The first step is light aerobic exercise for 5-10 minute periods with mild heart rate elevation and mild perceived exertion. This involves low intensity walking, spinning or jogging. There should be no weight lifting, jumping or running.
The second step is moderate exercise. Body and head movement should continue to be limited. Exercise time is moderate and less than the child’s prior level of exercise and includes moderate aerobic activity.
The third step is non-contact exercise that is more intense but without contact. Duration can approach prior levels and can include running, weight lifting and sport specific exercises. A cognitive component to the exercise can be added.
The fourth step is reintegration into full-contact practice with resumption of practice.
The final step is a return to competition.
This step progression must be done in collaboration with the physician, child or adolescent, parents, team support staff and all other caretakers who are involved in the care program.
Most children and athletes who suffer a concussion recover quickly and return to full activity and sport participation. If symptoms persist over time then a diagnosis of post concussive syndrome will be given and more extensive services and interventions may be required.