Concussion

So, I’m just going to get straight to the point. Concussions scare me. Anything that involves injury to one of our most vital organs makes me uncomfortable and is never something I want any of my patients to experience. What is even scarier to me is that I’ve found many have a nonchalant attitude towards this issue or don’t know much about it at all. A concussion is not something to mess around with. It can cause long-term consequences if not handled appropriately. Here’s what you need to know as parents:
According to 3 international symposia on concussion in sport (CIS), a concussion is a mild traumatic injury to the brain and can be caused by either a direct blow to the head or somewhere else on the body with enough force transmitted to the head. There are various ways one can sustain a concussion, such as playing football or soccer when two players collide and hit heads, or while recreating, like riding a bicycle and falling off and head meeting the ground. One could even be so unlucky to just slip on a patch of ice and smack their head on the ground. Now, typically, there will be some kind of immediate neurological impairment that will go on to resolve spontaneously, with or without a loss of consciousness. However, sometimes, signs and symptoms may not appear for minutes to hours after the blow initially occurred. A graded set of clinical symptoms will result from a concussion and resolution of these clinical and cognitive symptoms will often follow a set course. These symptoms fall into 4 categories: physical, cognitive, emotional and sleep. Physical signs include headache, nausea, vomiting, balance issues, visual changes, fatigue, light sensitivity, noise sensitivity and an overall dazed and stunned feeling. Some cognitive signs commonly experienced include trouble concentrating and impaired memory. Patients experiencing head injuries often have difficulty controlling emotions. They become easily angered or move from one emotion to another quickly. Sleep is often confused, with patients either experiencing more lethargy or conversely, trouble falling and staying asleep. Increased or prolonged drowsiness is a concerning finding in these patients as well.
If you think your child has sustained a concussion, he or she should be evaluated by a healthcare professional as soon as possible. Once evaluated, your child’s health care provider will determine if head imaging is warranted (in most cases it’s not). If all looks well and concussion is the diagnosis, your child’s health care provider will spend some time explaining activities and situations to avoid during a period of cognitive and physical rest. Cognitive rest could be anything from shortened days at school, to a temporary leave of absence from school, to a reduction in school workload or more time given to finish homework or exams. Video games, using a computer or tablet, and watching television should also be discouraged during this time as these require concentration and attention and can worsen symptoms.
In addition to cognitive rest, children who have suffered a concussion should be withheld from any kind of physical exertion until they are symptom free while at rest. This definition is broad and not only includes sports or the activity that caused the concussion in the first place, but other leisure activities that causes physical exertion, such as biking, skating, swimming, and jumping on trampolines, just to name a few.
Once your child is feeling symptom free at rest and would like to start participating in sports or other physical activities, a graded return-to-play progression is recommended (see here). Each step should be given 24 hours, and should take your child a minimum of 5 days to complete the protocol in order to get back to no limitation in activity. All of this is dependent on no symptoms returning. If there are any problems or if symptoms return while going through protocol, your child should stop that activity immediately. Once he or she is asymptomatic after another 24 hours of rest, your child should go back to the previous asymptomatic level completed and go on from there. Make sure to contact his or her health care provider if symptoms recur as well.

Now the big question is how long should your child undergo physical and cognitive rest and when should the symptoms resolve? The truth is, there is no set time. Most symptoms will resolve within 1 week and some take up to 2 weeks or more. If your child’s symptoms don’t resolve within 2 weeks, he or she could be suffering from post-concussive syndrome, which basically means they're experiencing 2 to 3 of those symptoms mentioned above for longer than 2 weeks. Again, not much can be done to help expedite the process except for giving them more time to recover. Making sure your child is symptom free before getting back to activities, especially contact sports, is the most important piece I want you take home from this post. Please, DO NOT let your child get back in that game or back on that bike or skateboard, until they are completely symptom free. So many times in clinic I've heard “But he has a big tournament this weekend” or “She will be heart broken if she can't play”. While I sympathize I can't stress enough the grave danger in sustaining a second concussion before symptoms of the first have resolved. It is called second-impact syndrome, and it can cause swelling in the brain that can lead to death. All reported cases of second-impact syndrome have been in patients less than 20 years of age. While extremely uncommon, it can happen. There is much truth to the saying “when in doubt, sit them out”. It's just not worth it.
Finally, is there a certain point to retire your child from one or multiple sports for the risk of getting another concussion? For example, what if your child had a concussion 1 year ago while playing hockey and just took a big spill off their mountain bike and suffered another 1? Unfortunately, there are no evidence-based guidelines that definitively give a number. It has been proposed that 3 concussions in one season or post-concussive symptoms that last greater than 3 months should warrant further conversation between you, your child, and his or her health provider regarding an extended time away from sports. As hard as of decision that may be, your child's safety and well-being are most important.
While we can't prevent all concussions from happening, the wearing of protective gear, identifying at risk athletes, and providing education regarding the dangers of concussions are the most important aspects of protecting our children.

Information presented adapted from:

American Academy of Pediatrics, Sport-Related Concussion in Children and Adolescents, http://pediatrics.aappublications.org/content/126/3/597

McCrory P, Meeuwisse WH, Aubry M, et al., Consensus statement on Concussion in Sport, http://bjsm.bmj.com/content/47/5/250.full.pdf+html