With going back to school, the start of football, volleyball, basketball and hockey season are upon us. School and local teams are gearing up and the first games of the season have started. This may be the perfect time to review concussion symptoms and management. Please note, I am not a physician. You should always consult first with a physician if you suspect your child might have a concussion. As a clinical neuropsychologist working with children and adolescents, I do assess cognitive symptoms that may be related to concussion or other mild traumatic brain injury, consulting with physicians, other health professionals, coaches and educators.
A large part of the information presented here is taken from recent research and guidelines from the Canadian Pediatric Society. In addition, some information is from a recent conference I attended on concussion in sport through The Mayo Clinic. Here are a number of questions and answers to help you understand what concussion is, and some basic information about management and prevention.
What is a concussion?
According to the CPS, a concussion is a result of either a direct blow to the head or somewhere on the body such that it transmits force to the head. The force from impact can affect the brain in a number of ways and cause brief neurological impairment.
What are the common symptoms of concussion?
There are a number of common symptoms associated with concussion, which fit into four categories:
Physical symptoms – headache, nausea, dizziness, visual disturbances, sensitivity to light or sound, amnesia, vomiting, slurred speech, loss of balance/reduced coordination, numbness, or loss of consciousness
Emotional symptoms – irritability, sudden mood changes, sadness, anxiety, or inappropriate emotions
Cognitive symptoms – memory impairment, confusion, slow responding or processing of information, reduced concentration, disorientation
Sleep symptoms – drowsiness, trouble falling asleep, sleeping more or less than usual
It is possible that symptoms in young children may not be as clearly defined. For example, a young child might complain of a stomach ache or that their head feels funny or strange. Any symptoms experienced by an individual following a possible concussion warrant an evaluation.
Note: Loss of consciousness occurs in 10% or less of all cases, and may not be an accurate predictor of concussion severity.
What should be done if a person is suspected of having a concussion?
The first and most important thing is to remove the individual from play, whether it is a game or practice, and not allow them to return for at least that game. If a concussion is suspected, but it is difficult to determine whether this is indeed the case, use the following: When in doubt, sit them out!
There are also a number of measures that can be used on the sidelines to assess for symptoms of concussion. However, these require some training to administer. Some coaches or team medical support staff can use these tools to assess symptoms of concussion on the field of play. For example, the Sport Concussion Assessment Tool 2 (SCAT2) can be used for individuals aged 10 or older. Measures specifically made for use with children and adolescents have yet to be developed. In addition, no one test has been developed to assess all symptoms of concussion or predict rate of recovery.
If the individual is unconscious, they should be removed from the field by medical professionals (ambulance staff, emergency or sport physicians), using all necessary precautions for spinal or other injury. Transfer to the hospital emergency department is often recommended in these cases.
Individuals that did not lose consciousness should be monitored closely, and complete an evaluation by a physician as soon as possible. It would be most helpful if the physician has experience working with athletes and/or concussion. The evaluation should include a full neurological assessment. A physician with experience in this area can provide management strategies (e.g., limiting cognitive and physical activity as the brain recovers), and develop a plan to monitor the child and help them slowly return to their activities.
The individual should not be left alone for the first 24 to 48 hours, and monitored regularly for deterioration in function or increased symptoms. Sleep is an important part of the recovery process, and children and adolescents should be allowed to sleep. If any signs of deterioration are noted, they should be brought to the emergency department immediately. It is very important that an individual does not return to play if they are still experiencing symptoms.
Who should be involved in evaluating a concussion?
The most important people are parents. You know your child, how they behave, their regular emotions, their thinking and learning abilities, their motor skills and balance, and general health. If you note any changes in these areas when monitoring them following concussion, it is important to bring them up with your child’s physician and coaches.
A physician with training in sports-related concussion is also important. They know the questions to ask regarding symptoms of concussion, can speak with parents and coaches about returning to play, and can help in developing a return-to-play protocol once your child is symptom free.
A neuropsychologist can help to assess for cognitive symptoms that the child might be experiencing, which are not always as apparent. This might include assessing memory, attention, processing speed or reaction time, and such things as planning or problem-solving. Completing a neuropsychological assessment may help parents, coaches, physicians and schools understand the impact of a concussion on a child, and provide additional supports to the child or adolescent as they return to their normal life (school, sports, friends, etc.). Some health teams use a computerized testing program to screen for cognitive symptoms, although it is helpful to supplement these programs with paper-and-pencil testing completed by a neuropsychologist, especially if a child or adolescent continues to experience symptoms longer than would be expected or more severe symptoms.
Unless a neuropsychological or psychoeducational assessment was completed prior to the concussion, it may be difficult to determine whether some learning or thinking difficulties were pre-existing, or are new. Regardless, putting supports in place as your child or adolescent recovers from a concussion is paramount. Not only may they require a gradual return to play, but they may also need a gradual return to other activities, such as school and homework.
How long do symptoms generally last?
This can be quite variable. Typically, following a single concussion, symptoms generally resolve within 7 to 10 days (this occurs in 90 to 95% of adolescent athletes, according to research). However, some individuals can experience symptoms that last weeks, even months. Some research has shown that younger children take longer to recover from concussion. Cognitive symptoms may also take longer to resolve in children and adolescents. This may be because their brains are still developing, and may have different neurobiological responses to injury than an adult brain. Further research is needed in this area.
Concussion symptoms may resolve for an individual while they are at rest (i.e., not engaged in physical activity), but symptoms may return when they begin to exercise or engage in cognitive activities. In this case, they would not be considered ‘symptom-free’.
Are there any complications that could occur following a concussion?
Yes, there are, although complications are rare. One complication that occurs primarily in children and adolescents is something called ‘malignant brain edema syndrome’. This is thought to be caused by a problem with regular blood flow to the brain, leading to increased pressure and swelling in the brain. This can cause the brainstem to herniate, possibly leading to coma and death. A second rare (and often fatal) complication is called ‘second impact syndrome’, which also occurs in young athletes. It is thought to happen when a youth experiences a second concussion while symptoms from the first concussion have not yet resolved. However, research supporting this theory is not yet available, and more research is needed.
What factors can affect concussion severity and recovery?
There is still a lot of research to be done in this area. However, factors such as a child’s age, a history of multiple concussions, or a co-morbid disorder such as a learning disability may affect recovery and how your health team manages your child’s treatment. It is important to tell your health team about these factors to ensure they are considered in treatment planning. For example, it is possible that having a previous concussion can increase the risk for another head injury, and more severe symptoms. As such, a player with a history of multiple concussions may need a more conservative treatment plan.
Are there things we can do to prevent concussions?
It is important to note that helmets currently prevent such things as skull fractures or open traumatic head injuries. Helmets are very important and necessary in keeping your child’s head safe from the outside, and should be worn when engaging in most sports. When a child or adolescent wears a helmet, it may make them feel safe and think they are not at risk for a head injury. Children and adolescents should be reminded that while a helmet protects them from some head injuries, it does not protect them from all head injuries. There is currently no helmet or other safety device that can keep your brain safe and free from the effects of an impact to your head or body. Reducing aggression in sport, as well as teaching players appropriate sporting techniques (e.g., proper body checking in hockey) can be helpful in reducing concussion. In addition, some sporting rules have been changed to help reduce the likelihood of concussion, such as no checking for younger hockey teams. Educating players, coaches, trainers, parents and health professionals about concussion symptoms and management can help ensure players are aware of and reporting symptoms, and proper return to play management is enforced.
If you want to learn more about concussion, here are some additional resources that you might find helpful.
University of Toronto Concussion Program
Canadian Pediatric Society Guidelines for Evaluation and Management of Concussion
Think First Brain Injury Prevention
Teenage Boys’ Brains Tested to Gauge Concussion: Article in The Toronto Star
Still Much to Learn About Hockey Concussions: Article on CBCSports.ca