Concussion Facts

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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.

Concussion And Brain Rest

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After your child has been diagnosed as having a concussion the first step is to discuss the injury with your family and your child. The stress of the injury and the diagnosis can be difficult but convincing your child to allow his or her brain to “heal” can be even more difficult. Your child’s brain needs time to recover. This is a time when your child needs to avoid all physical activity beyond light walking and if light walking causes symptoms including headache, dizziness or vision changes then your child needs to avoid physical activity.  Mental activity including television, movies, video games, text messaging and any activity beyond simply quieting the brain needs to be avoided. Spend time together listening to soft music or the sounds of nature. Consider reading to your child and helping them take several naps throughout the day and always pursue a restfull sleep for 9-10 hours each night.  The sooner the recovery begins the faster the concussion symptoms will resolve. Any activity that prevents this recovery will cause the symptoms to last longer and possibly worsen.

Parents play the most important role in this recovery process. You have the relationship and capability to convince your child about the importance of rest and can intervene immediately if you see signs of anxiety or difficulty coping with injury sequellae. You know your child best. Even a trained eye can miss signs of mood, behavior or cognitive difficulty that you easily recognize. Speak up! Do not allow your child to return to activity before all symptoms have resolved. Seek help and advice and stay in close contact with your pediatrician.

Studies clearly show a concussion disrupts brain function and will only heal with time. Brain blood flow decreases after a concussion and this robs the brain of vital energy sources. Your brain relies on glucose for energy. In the days and weeks after a concussion it is as if someone blocked off several streets and you are unable to drive to the store. By decreasing activity and cognitive work load, more glucose is available for your brain to heal. This is the time when the brain is most vulnerable. It is as if you have left a bedroom window open on a cold and blustery winter day. You walk into the bedroom and feel a cold draft and know how hard your furnace has been working all day to keep up with the loss of energy. Don’t let this happen to your child’s brain.

Engage the whole family in this process. Sibs and friends need to understand the need for rest and a very gradual return to activity. These guidelines are called “return to learn and return to play” rules. Inform school staff and all who are involved in the caretaking of your child. This is a team effort and with time and patience the overwhelming majority of children recover fully within several weeks. If your child continues to have symptoms after 3 weeks of rest, has worsening symptoms or if he or she has a history of a prior concussions or an underlying neurologic problem including a seizure disorder, a migraine headache disorder, learning problems, ADHD or mental health problems then seek expert help and guidance.