Julia M. Kerrigan M.D.and Christopher C. Giza M.D.
Christopher Giza, MD
Christopher Giza graduated from Dartmouth College, received his M.D. from West Virginia University and completed his internship at the University of Pennsylvania. Dr. Giza then trained in Adult and Pediatric Neurology at UCLA. He then worked on the Yosemite Search and Rescue team before joining the UCLA Brain Injury Research Center. Dr. Giza traveled to Afghanistan in 2011 as a civilian advisor to the Department of Defense. He founded and directs the UCLA Steve Tisch BrainSPORT program, and also serves as Medical Director for the Operation MEND-Wounded Warrior Project mild TBI program. Dr. Giza co-chaired the American Academy of Neurology’s committee that developed an evidence-based Sports Concussions Guideline. He helped develop the Youth Mild TBI guidelines for the Centers for Disease Control and the most recent update by the International Consensus Conference for Concussion in Sport (Berlin guidelines). He currently serves on advisory committees for TBI/concussion with the CDC, NCAA, NBA, MLS and USSF, and has been a clinical consultant for the NFL, NHLPA and MLS. He is currently Professor of Pediatric Neurology and Neurosurgery at the David Geffen School of Medicine and Mattel Children’s Hospital-UCLA.
Julia M. Kerrigan, MD
Julia Kerrigan is a general neurologist who is further specializing in Sports Neurology-Neurotrauma at UCLA. She has a unique interest in the field due to her background. Dr. Kerrigan was an All-American scholar athlete while playing Women’s Basketball at Westmont College in Santa Barbara, CA, prior to heading to Oslo, Norway where she played professional basketball and continued her academic research. Dr. Kerrigan obtained her medical degree at the University of Minnesota Medical School and completed her Neurology Residency at Harbor UCLA Medical Center. She thereafter joined the UCLA Steve Tisch Fellowship Program where she is able to combine her love for sports and medicine to help those with acute and chronic complications following concussion.
A concussion is a biomechanically induced traumatic brain injury (TBI) characterized predominantly by recoverable brain dysfunction. Across the spectrum of TBI, it is often referred to as “Mild TBI (mTBI).” Despite this term, it is a potentially serious injury that needs careful evaluation. A concussion often is the result of a direct hit to the head, but can also happen from a blow to the body that causes the movement of the brain within the skull. The brain is floating in fluid (cerebrospinal fluid) and sudden forceful movement can cause the brain to bounce and twist around, hitting against the skull, causing stretching of brain cells, and chemical changes in brain function. This trauma to the brain can cause temporary signs and symptoms of neurologic dysfunction that usually recover with time.
Concussion symptoms a child may tell you they are experiencing can include:
- Headache or “pressure in the head”
- Confusion, problems with memory or concentration
- Dizziness or lightheadedness
- Nausea or vomiting
- Problems with balance, double or blurry vision
- Easily bothered by light or noise
- Feeling drowsy or having sleep problems
- “I just don’t feel right,” feeling hazy, foggy or groggy
Observed signs of concussion can include:
- Dazed or confused, stunned, blank stare, slow to answer questions
- Clumsy movements, changes in balance, coordination or reaction times, slurred speech
- Difficulty recalling events before or after the hit, memory loss
- Personality, behavior or mood changes, trouble controlling emotions
- Loss of consciousness/blackout (occurs in <10% of diagnosed concussions)
If a child has one or more of these signs or symptoms following a blow to the head or body, then they should be evaluated immediately by a licensed health care provider. There is no single test to diagnose concussion, so the diagnosis must be a clinical determination, based on history, physical and neurological examination. Athletes must not return to play the same day and must be cleared by the provider before they can play again. When in doubt, sit them out! Sometimes signs and symptoms don’t always show up right away and may progress over hours to days, therefore any worsening should prompt a call to the doctor or a trip the emergency room.
The brain requires time to heal. The chemical changes in the brain make it more sensitive to stress or another injury until it recovers. Parents, teachers and coaches should all be aware of a diagnosis of concussion and physically or mentally taxing activities should be initially reduced to allow time for full recovery. Health care providers should give a written plan of instructions for when to return to school and specific guide with step-by-step instructions for gradual return to physical activity, which usually takes place over days to a week or two. Concussion affects each child differently and a subset of kids may still have symptoms including trouble sleeping, headaches, difficulty with concentration or reaction time, and sensitivity to noise or sound for weeks, months, or even longer.
Traumatic brain injury (TBI) has historically been differentiated as mild, moderate, or severe using the Glasgow Coma Scale. Concussion is a type of mTBI and has been defined as any trauma-induced transient disturbance of neurologic function and mental state, with or without loss of consciousness. This trauma to the brain can occur from a bump, blow, or jolt either to the head or body that causes the brain to move inside the skull. Each year in the United States, up to 3.8 million people sustain a sports related TBI with the highest rates occurring in youth and adolescents. Pediatric TBI is a special consideration due to the age-related physiological responses and differential recovery of symptoms after concussion. When associated with organized sports, concussion may be managed using pre-season and post-injury neurologic and cognitive testing, close monitoring and treatment of symptoms, reassurance and education, gradual reintroduction to activity, and implementation of prevention strategies.
In the past, sports concussions were commonly referred to by the terms “bell ringer” or “ding,” and nearly one-third of these players would return to play the same day. Coaches, parents, and players often had a common mentality that the athlete had to “shake it off” and “take one for the team.” However, these terms result in a more cavalier attitude toward acute brain dysfunction that can put a player at risk for even further injury. Proper evaluation of mTBI is important so as to not miss any rare associated intracranial injury. Such possibly catastrophic injuries can range from cerebral swelling, skull fracture, intracranial bleeding (cerebral contusion, cerebral laceration, epidural, subdural, or subarachnoid hemorrhage) or diffuse axonal injury (stretching and shearing of white matter tracts).
In athletes who have sustained a concussion, there is up to a three-fold risk of subsequent concussion in that same sports season. The reason for this is not known, but it is thought it may be related to athletes returning to play before complete recovery. In this setting, there may still be physiological vulnerability as well as subtle coordination and reaction time impairments that increase risk for subsequent injury. These types of risks will diminish as the brain heals and recovers. Another contributor to repeated concussions may be a risky style of play in certain athletes; this does not diminish with recovery time and requires proper coaching and training.
A majority of sports concussions occur without loss of consciousness or obvious neurologic signs. Symptoms often include dizziness, headache, photophobia, phonophobia, and nausea. Visible signs may include confusion, amnesia, vomiting, incoordination, unsteady gait, but in the majority of instances there is no loss of consciousness. The cause of these symptoms is thought to be due to temporary brain dysfunction that recovers with time. Although concussion in kids may have similar symptoms to adults, there are multiple distinctions that pediatric practitioners must be aware of. First, the description of subjective symptoms may be different in children and parental co-reporting may be necessary to understand the complete symptom burden. Terminology used to describe the concussion should be simplified so that the child can understand. Neurocognitive function changes across developmental ages, so age-appropriate testing and validated tools must be used. Finally, recovery in children and adolescents is a complex process that includes symptom resolution, re-integration to school, socialization, return to physical activity and, often, return to the at-risk sport.
Concussion is a clinical diagnosis and while symptoms are usually short-lived and resolve spontaneously, in some instances signs and symptoms may only evolve over minutes to hours. The diagnosis can include one or more of the following clinical domains. If any one or more of these components are present, a concussion should be suspected and the appropriate management strategy instituted, including immediate removal from play. It is important to keep in mind that in sports concussion, an individual athlete’s subjective reporting of symptoms may not always be reliable due to underlying motivation to return to play. It is also not uncommon for a concussed child to be unaware that they are injured. Therefore the ultimate diagnosis needs to be made by a licensed health care professional experienced in concussion.
- Symptoms: somatic (e.g., headache, dizziness, nausea or vomiting, blurry or double vision), cognitive (e.g., confusion, feeling like in a fog) and/or emotional symptoms (e.g., lability)
- Physical signs (e.g., loss of consciousness, vacant staring, dazed or stunned, incoordination, imbalance, slurred speech )
- Behavioral changes (e.g., irritability, personality changes, lethargy, listlessness, disorientation)
- Cognitive impairment (e.g., slowed reaction times, impaired memory)
- Sleep disturbance (e.g., insomnia)
Rarely, more serious intracranial pathology or bleeding could be present after a suspected concussion. If the child shows one or more of the following ‘red-flag’ danger signs, then urgent medical evaluation is indicated.
- Worsening or persistent severe headache, nausea, or vomiting
- Increasing confusion, drowsiness, or inability to wake up
- Seizures or convulsions
- Weakness or numbness, slurred speech, decreased coordination
- One pupil larger than the other
- Even a brief loss of consciousness should be taken seriously
- Infants or toddlers who will not stop crying, cannot be consoled, or will not nurse or eat
Mechanisms of Injury
The time of highest risk for pediatric TBI is in adolescence, with a secondary peak in infancy. The cause of the TBI varies with age. Teens sustain the majority of head injuries in motor vehicle accidents, assaults, or sports-related concussions. Pre-adolescent children are more often pedestrian victims of motor vehicle accidents, while children under the age of 5 are more prone to falls and infants are vulnerable to abusive head trauma. Pediatric sports concussions are a common problem occurring in contact sports such as football, soccer, hockey, basketball, wrestling and cheerleading among others. Concussions do not just happen to athletes, however, and can occur any time the head or body comes into contact with a hard object, such as another child’s head, a desk, or the ground. Other recreational activities that are commonly involved in concussion include bicycles, skateboards, scooters, and rollerblades.
The forces applied to the brain in traumatic brain injury can be described as linear or rotational; however it is generally difficult to separate the two. Acceleration or deceleration forces in a straight line can cause the brain to move as it floats in cerebrospinal fluid, causing compression of the brain at the side of contact and on the opposite side of the skull as it flows backwards.
Physiologic studies in concussion have demonstrated abnormalities in brain metabolism, activation and axonal dysfunction. There can be dramatic reductions in cerebral glucose metabolism, meaning the way the brain uses its energy resources that can last for days. Task specific brain activation patterns have been shown to become less focused and more diffuse in the injured brain. It appears the brain tries to find alternate ways to get things done while healing.
Coaches, teachers, and parents are key in immediate action in the case of suspected pediatric concussion. They should not be seeking to diagnose concussion; if a concussion is suspected, the child should be removed from play. Key information that responsible adults obtain after the injury can help a health care provider in their assessment, include the following:
- What was the cause of the injury? Where were they hit? Approximately how hard?
- Was there any loss of consciousness?
- What symptoms were present and for how long?
- Was there any memory loss right after the injury?
- Were there any seizures?
- Have there been concussions in the past? How many?
The most important rule for non-medical responsible adults evaluating a child with suspected concussion on the sideline is “When in doubt, sit them out!”
Medical providers on the sideline have a more challenging task. Concussion is a clinical diagnosis based largely on observed injury mechanism, clinical symptoms, and physical signs, and which usually involves the assessment of a range of domains. In the initial period after a potential TBI, the patient should be evaluated by a licensed health care provider onsite using standard emergency management principles, including ABCs (Airway, Breathing and Circulation). Particular attention should also be given to excluding cervical spine injury. If a TBI more serious than a concussion is suspected, the patient should be stabilized and transported for emergency medical care.
Once any emergency issues are addressed and the injured child appears stable, care should be taken in obtaining the history of injury, including symptom onset and course, as well as a focused physical and neurologic exam. A detailed clinical assessment of concussion using the Sports Concussion Assessment Tool (SCAT3 or child SCAT3) or other sideline evaluation tool should be performed, preferably in a quiet location with few distractions. If concussion is diagnosed, the player should not be allowed to return to play the day of the injury. If no provider is available, the player should be removed from practice or play, not be permitted to return that day, and referred for medical evaluation by a licensed health care provider with experience in concussion. Over the initial minutes and hours following injury, the player should periodically be reassessed, as symptoms may evolve during this time. However, waking a child up throughout the night is not necessary.
The SCAT3 is a multimodal screening assessment for use in athletes age 13 years and above; the screening includes a symptom checklist, cognitive screen (Standardized Assessment of Concussion or SAC) and balance test (Balance Error Scoring System or BESS). The SCAT3 is an instrument designed for use by non-physician medical providers (like certified athletic trainers) on the sidelines of a sporting event and has been validated to identify the presence of concussion in early stages post injury. However, the SCAT3 is not meant to be a stand-alone tool for ongoing management of sports concussions. The ChildSCAT3 has been developed for use in those <13 years, yet is still awaiting formal validation. It does incorporate simpler symptom questions, a parent co-report, and simpler cognitive and balance screening than the SCAT3.
The SAC is a cognitive screen embedded in the SCAT3 designed for brief administration to assess four cognitive domains: orientation, immediate memory, concentration, and delayed recall. Of note, proper instruction is necessary for valid administration of these tools in the evaluation of the athlete with suspected concussion. Comparing results to baseline scores on concussion assessment tools can be helpful especially in younger athletes, those with prior concussions, or with preexisting learning disabilities. It is important to recognize that baseline neurocognitive scores may change with age, so if comparisons to baseline are used, they should be made with the most recent testing, preferably within the last year.
Clinical balance assessments for postural stability can be a reliable and valid additional tool for assessing the motor domain of neurologic functioning, especially where there are signs or symptoms of balance dysfunction. These include the Balance Error Scoring System or the more sophisticated force plate technologies such as the Sensory Organization Test. Studies have shown such tests have identified acute postural instability lasting approximately 72 hours following sports-related concussion.
The King–Devick test is a timed number-reading test that screens for oculomotor dysfunction. Rapid number naming requires intact eye movements in addition to language and concentration and typically takes <1 min with no errors. Following concussion, the accuracy and speed of this test may decrease. This can be used in combination with other modalities (like SCAT3) for more accurate diagnosis.
Emergency Room or Doctor’s office:
Initial or secondary contact following pediatric concussion may be in the Emergency Room or at the doctor’s office. A thorough medical assessment including a comprehensive history, whether there has been any improvement or deterioration since injury, and a detailed neurologic examination including assessment of mental status, cognitive functioning, gait and balance should take place.
In pediatric concussion there is a legitimate concern about the risk-benefit ratio of computed tomography (CT) due to the radiosensitivity of the developing brain. Computed tomography scans are typically not indicated for evaluation or diagnosis of concussion, however if a more severe brain injury is suspected, then CT may be indicated. There are excellent clinical prediction rules for when to obtain a CT scan after pediatric concussion, including the PECARN Pediatric Head Injury/Trauma Algorithm. These validated prediction rules can significantly improve value of care by reducing unnecessary CT scans in children, therefore reducing radiation exposure. The PECARN analysis excluded children with Glasgow Coma Scale (GCS) score of less than 14 for whom the use of CT is not controversial. In summary, for children 2 and older seen in an emergency department, a CT scan is recommended if the Glaskow Coma Scale is 14 or less, there are signs of altered mental status, or signs of basilar skull fracture. The study reports this group is approximately 14% of the population with a 4.3% risk of clinically important TBI (ciTBI). In 27.7% of the population there may be a history of loss of consciousness, vomiting, severe headache. or severe mechanism of injury. These patients were shown to have a much lower risk of ciTBI (0.9%). In these cases, the decision can be made between observation versus CT based on clinical factors including physician experience, multiple versus isolated findings, worsening symptoms or signs after emergency department observation, and parental preference. In 58.3% of the population there will be none of these symptoms or exam findings present and the risk of ciTBI becomes exceedingly low, dropping to <0.05%. A CT scan is not necessary for patients in this group.
Other advanced imaging modalities such as functional magnetic resonance imaging (fMRI) which can demonstrate altered patterns of network activation, magnetic resonance spectroscopy (MRS) which can demonstrate abnormal cerebral metabolites, diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) which can show restricted diffusion, susceptibility weighted imaging (SWI) which can detect hemorrhages and diffusion tensor imaging (DTI) which can show perturbations in diffusion along white matter tracts have all been reported to show changes after pediatric TBI. Currently, these are indicated only for research purposes and are not part of routine clinical assessment.
The application of neuropsychologic testing (either paper and pencil or computerized) has been found to be clinically useful in identifying and managing concussion. Typically the assessment includes testing memory performance, reaction time, and speed of cognitive processing. There are multiple brands of computerized neuropsychologic testing; none has been proven superior to the others, and all should be used with a good understanding of the indications and limitations of the tool. It is advisable to have a neuropsychologist available to ensure proper administration, training of staff, and interpretation of these tests. Cognitive recovery has been found to largely overlap with the time course of symptom recovery in most cases and should be an important component in the overall assessment of concussion in conjunction with a range of assessment of different clinical domains.
Formal neuropsychologic testing by a trained neuropsychologist is not required for all concussions, but may be used to assist return to play and return to school decisions, particularly in settings of cognitive and attentional comorbidities, individuals with persistent post-concussion symptoms, and those with a history of multiple repeated concussions or prolonged impact exposure. Neuropsychologic testing is typically performed when a child’s symptoms are already improving. If cognitive testing is performed, it must be developmentally sensitive until the late teen years due to ongoing brain development during this period, which also limits comparing to baseline performances of the patient or the population norms.
After thorough assessment and diagnosis of concussion, treatment should include an individualized management plan, including specific instructions for return to school, return to physical activity and, lastly, return to contact risk. Open communication with families is essential regarding weighing the potential risks of repetitive concussions versus the benefits of sports participation.
It is key to understand there should be no return to play on the day of the concussive injury. Not only is there a greater risk of another concussion, with over 90% of repeat in-season concussions occurring within 10 days of the first concussion, but also a repeat concussion that occurs while the brain is still healing can be more serious than the initial concussion and may prolong recovery. Acutely, the brain is in an energy crisis with slower reflexes, reaction time, and cognitive function which can result in poor playing style and may put the athlete at risk for either repeat concussion or other musculoskeletal injuries. This biological vulnerability generally recovers over time, but reinforces the concept that interval between impacts matters.
There is no set timeline for recovery from concussion. The cornerstone of management is an initial period of rest following injury (24-48 hours) followed by gradual return to school and social activities, then non-contact physical activity in a manner that does not result in a significant exacerbation of symptoms. The child should get plenty of rest and try to keep a regular sleep routine with no late nights or sleep overs. The term “cognitive rest” refers to a child’s need to initially limit activities that may involve a lot of concentration or cause symptoms to come back or get worse. Examples of such activities might include screen time (phone, computer, video games, TV), studying, and school attendance, but each should be managed individually. However, it is key that the child is not given “cocoon therapy” which had been recommended in the past. Instead, limited and gradual return of screen time and social interaction is likely necessary for emotional stability and return to normalcy, especially in the teen years. Strict school absence and complete physical inactivity longer than a few days may actually end up prolonging recovery.
Return to school should be the first goal after acute rest; this step requires collaboration with school administration and teachers. When kids or teens are very symptomatic in class they aren’t learning well and they often may require a few days of modifications such as shortened days or classes, rest breaks, extra help, reduced homework, or postponed testing acutely following injury until recovery. Most will only need help through informal academic adjustments, but for those with ongoing symptoms, there are a variety of formal support services that may be available to help them during recovery — such as a 504 plan or individualized education plan. Formal accommodations should not be undertaken lightly, but are occasionally necessary for children with prolonged symptoms or complicating comorbidities.
Return to play progression represents a stepwise process that providers ideally can adjust and develop individualized gradual plans for return to physical activity, with each step taking at least 24-48 hours with advancement to the next level if asymptomatic or improving. Typically this takes 1 week or more to proceed through the full rehabilitation progression, but if symptoms emerge or flare up at a certain level, they should drop back to the last tolerated level and try to progress again after a further 24 hour period of rest has passed. An athlete’s parents and coaches should watch for concussion symptoms during and after each day’s progression of activity.
Generally, more conservative management should be given to younger pediatric patients compared to older athletes. Keep in mind that the child should initially be avoiding high risk or high speed activities that could result in another concussion until their medical provider says they are well enough. This can include playing sports, but also bicycling, skateboarding, roller coasters, or simply climbing playground equipment.
Post-concussive syndrome is a grouping of symptoms that can include post traumatic headaches, dizziness, behavioral changes, fatigue, irritability, inattention, poor concentration and sleep problems. Post-concussion syndrome is not uniformly defined; it may be more appropriate to consider these patients as having persistent post-concussion symptoms . Often following concussion there is a tendency to ascribe any symptoms a child or teen is having to the injury. Many symptoms such as headaches, inattention, fatigue, or memory lapses may have been present prior to the TBI and were likely underestimated at that time. Cognitive restructuring is a form of brief psychological counseling that can be administered by providers and consists of education, reassurance, and reattribution of symptoms. Using both verbal and written information to further educate patients and families has shown benefit in reducing symptoms and decreasing the number of individuals who develop chronic symptoms.
Ten to thirty percent of concussion patients have persistent symptoms, with different rates based upon setting of presentation (emergency department, primary care clinic, specialty clinic) as well as the time interval from injury. For many concussions, proper management and education can and should occur in a primary care setting. In cases with more persistent or unusual symptoms, it is important to manage in a multidisciplinary manner by healthcare providers with experience in concussions. Providers are encouraged to evaluate for symptoms of depression and anxiety, which are common in all forms of traumatic brain injury and are often multifactorial in nature. Symptom-targeted therapy is sometimes indicated in cases with headaches, insomnia, dizziness, attention problems, visual disturbances, depression, or anxiety. These interventions may include medication, physical or occupational therapy (including vestibular), sleep hygiene, controlled exercise, reassurance, cognitive behavioral therapy, educational counseling, or psychotherapy. However, it should be noted that for return to full contact practice or play, patients should not be taking any medications that may mask the symptoms of concussion.
Post-traumatic headaches or migraines are not uncommon acutely following concussion, but can also occur in children on a chronic basis. Management is typically directed at the presumed underlying etiology of the headache. Headaches may be treated with analgesics including NSAIDs, acetaminophen or a short course of a stronger anti-inflammatory medication such as indomethacin. Acute infrequent migraines can be treated with abortive medications such as ergots or triptans. Preventative supplements or medications may be indicated for headaches occurring more than once or twice every few weeks. Migraine prophylactic medications and supplements vary in their efficacy and options can include magnesium, riboflavin, amitriptyline, nortriptyline, topiramate, valproic acid, beta blockers, calcium channel blockers, serotonin reuptake inhibitors, or gabapentin.
Children or adolescents with concussion can also have sleep disturbances. Typically behavioral changes like improved sleep hygiene are the first line of therapy. For more chronic sleep changes, supplementation with melatonin could be considered; polysomnography may be indicated in rare cases.
In rare cases, acute confusional migraine, cortical blindness, and impact seizures may occur following pediatric concussion. Due to the nature of these symptoms, these are diagnoses that are only made after more serious intracranial pathology has been excluded. Impact seizures generally occur immediately upon impact, are non-focal and typically self-limited episodes with complete recovery within minutes. Acute confusional migraine is a predominantly behavioral syndrome that can occur after concussion where a child becomes progressively more agitated and combative followed by a period of fatigue and sleep. The presence of headache can be variable. Sometimes the child will recover with no recollection of the earlier events. Additionally, children may report a post concussive syndrome of cortical blindness, leading some to suspect malingering since pupillary responses are preserved. It is suspected that migraine, spreading depression, or other neurovascular abnormalities may contribute to this phenomenon and complete recovery is the rule.
Second Impact Syndrome is a controversial term that is clinically described as a syndrome involving catastrophic brain injury after consecutive concussive episodes with incomplete recovery between. The mechanism is theoretical based upon the interpretation of a small number of anecdotal cases and is thought to occur from a second concussion before complete recovery from the first concussion, resulting in alterations in cerebrovascular function, cerebral edema and, sometimes, death. There is little direct evidence to support the concept, leading some to doubt the validity of the diagnosis. However, diffuse cerebral swelling following even a single blow to the head is a well-recognized but rare sequela of head injury. Therefore, in any case, it is important to reinforce the rule of protecting the brain from additional impact risk after the initial injury.
Resolution of the clinical and cognitive symptoms typically follows a sequential course with 80-90% of concussions resolving in a few weeks. However, in some cases symptoms may be prolonged, especially in adolescents when compared to adults or younger children. A subset of patients will have symptoms for months or longer. Parents should be in contact with their medical provider if their child is not recovering as expected.
There are various factors that may have an influence on prolonged symptoms. Those with multiple previous concussions collectively have a longer duration of symptoms and length of recovery. Other predictors of persistent post-concussive symptoms can include:
- Number and severity of ongoing clinical symptoms
- Younger age as compared to adults, although adolescents appear to often take longer than young children
- Preexisting learning disabilities, premorbid personality traits, medicolegal compensation and family dynamics may also be factors
- Early posttraumatic headache, amnesia, alteration in mental status, and fogginess or fatigue are probable risk factors
- There is currently insufficient data to conclude whether sex is a risk factor for chronic post-concussion problems, but some have proposed that females may have longer recovery
Post-concussive syndrome, or persistent post-concussive syndrome, can have significant implications for returning to normal activity especially in school aged children. As possible, management of post-concussive syndrome in children should focus on return to normalcy since prolonged absence from school can become overtaken by issues of anxiety, depression, falling behind, physical and mental deconditioning and, sometimes, secondary gain. Providers and parents should keep in mind possible influence the patient may be getting from other parties such as coaches, teachers, or teammates. There is evidence that persistent post-concussive syndrome is more likely in adolescents (compared to younger children or adults), perhaps at least in part due to these many environmental and social factors.
Education and Reassurance
In regards to sports safety and primary prevention, pre-participation counseling is key. The decision to participate in sporting activities is clearly an individual one, but should include an understanding of the relative risks for concussions, the uncertain long-term risks in amateurs, and the physical and social benefits of participation in youth. Child neurologists and other health care providers should be a resource to provide up to date information about these points to our patients and families. The number one predictor of recurrent concussion is a history of concussion. Number of concussions overall is approximately twice as common in boys compared to girls, especially as they get older. However, in sports with similar rules between sexes, like basketball or soccer, the risk for concussion is greater for female athletes.
Different sports have different risks for causing concussions. In general, combat sports (boxing, mixed martial arts, wrestling, etc) likely have the highest risk. This is followed by collision sports, where physical contact between players is an integral part of the game (football, ice hockey, rugby, boy’s lacrosse, etc), and then contact sports, where contact occurs but is ‘incidental’ (soccer, basketball baseball, girl’s lacrosse, etc). Lowest risk is in noncontact sports, although it is possible to sustain a concussion or TBI in any activity. It can also be difficult to calculate comparable risk in ‘extreme sports’ such as cycling, skateboarding, skiing, snowboarding, etc, as there is potential risk for concussions but, due to speed, there is greater risk for more serious TBI also, including skull fracture and intracranial hemorrhage.
As for protective equipment, there is insufficient data to support or refute the superiority of one type of football helmet over another. Helmets were created to lower the chances of the most serious or deadly types of brain or head injury, but there is no “concussion-proof” helmet. Helmets that are well fitted with approved design may decrease the impact of the hit, but this does not eliminate concussions, since the brain may still be shaken around inside the skull. In various sports such as skiing, snowboarding, cycling, and horseback riding, helmets may additionally help prevent more severe head injuries such as skull fractures and are still important for injury prevention. There is currently no evidence to demonstrate that head gear worn in soccer or basketball is effective at preventing concussions. Mouth guards are often used to prevent dental injuries, but there is not enough evidence to show if they help prevent concussions. It is important to consider that those wearing ineffective equipment might adopt more risky playing techniques if they feel less vulnerable.
It is important to objectively and clearly address fears of parents and athletes from the media pressure related to the possibility of chronic traumatic encephalopathy. Chronic traumatic encephalopathy represents a tauopathy with an unknown incidence in athletic or other populations and is only diagnosable after death. Despite many high-profile case reports, a cause and effect relationship has not as yet been demonstrated between chronic traumatic encephalopathy and concussions or exposure to contact sports. Long-term significance of a single concussion is uncertain and currently there are no published studies that specifically address long-term cognitive consequences of repeat pediatric concussions. In professional athletes there has been evidence of a relationship between multiple head impacts or concussions and chronic neurobehavioral impairments. The risk in these studies appears to be dose dependent related to the amount of contact exposure or number of concussions. Similar studies in amateur athletes (including high school students) have been mixed, with many showing neurocognitive impairments in life, but almost equal numbers showing no detectable impairment.
Retirement from play after multiple concussions is usually a family decision after taking into account all information available and weighing the child’s benefits and risks of participation in the sport. A helpful evaluation tool in the case of a history of multiple concussions and subjective persistent neurobehavioral impairments is a formal neuropsychological assessment to help guide the decision process. Providers caring for athletes who show objective evidence of chronic neurologic or cognitive deficits should discuss retirement from the contact sport to minimize risk for and severity of chronic neurobehavioral impairments. Relative indications to suggest retirement from a particular sport also include a lower threshold to injury, progressively longer recovery times after subsequent injuries and/or intractable pain or other symptoms.
Knowledge is currently the first step in concussion prevention. Education of parents, teachers, coaches, athletes, referees, administrators and the general public in regard to signs, symptoms and significance of concussions, assessment techniques, and principles of safe return to play is key.
Help lower a child’s risk for getting a concussion:
- Make sure the coaches have been educated by a licensed health care professional regarding concussion
- Provide appropriate sideline medical care where possible with a certified athletic trainer or other licensed health care provider.
- Follow sport specific rules and proper technique for safety and concussion prevention
- When appropriate for the sport or activity, ensure helmet is worn, is properly maintained and fits well
- Emphasize fair play and respect for opponents
- Avoid hits to the head
- Make sure each child knows the signs and symptoms of concussion and to watch out for themselves and others
- Emphasize the importance of reporting concussions and need for recovery time
- Remind children and teens that it is better to miss one game than the whole season
There is continued need for research in regards to many aspects of concussion diagnosis, management, and sequelae, especially in the pediatric population. Despite increasing public awareness in recent years, concussion has still been found to be under reported and under diagnosed. Legislative actions in all 50 states have begun to mandate aspects of education and management of youth sports concussions. However, existing guidelines for assessment and management remain largely consensus based, derived from data generated from high school and college athletes, with very limited data from pediatric populations. In addition, there is a wide variety of provider experience and training causing uncertainty and inconsistency in management. Even though there are guidelines available to help health care providers progress individuals through a graduated return to play, there is a need for more specific data to develop management strategies for younger children. Technological developments are underway to improve assessment of mild TBI. While not yet ready for “prime-time” clinical management of individual patients, newer imaging techniques, impact sensors, electrophysiological measures, and molecular biomarkers are promising future tools. For now, neurologists and other health care providers need to use their excellent clinical skills, a toolbox of validated assessments to support diagnosis and follow recovery, frequently update knowledge in evidence-based practice, and continue balanced brain safety education. Greater awareness is something everyone can participate in and there are many resources available to help you get involved in your community and schools.
- Amnesia – A partial or total loss of memory.
- Attention Deficit Hyperactivity Disorder (ADHD) – A neurodevelopmental disorder characterized by impaired or diminished attention, impulsivity and/or hyperactivity
- Cerebrospinal fluid (CSF) – A watery fluid that flows within the ventricles of the brain and around the surface of the brain and spinal cord.
- Cognitive functioning – Higher order mental processes that help us gather and process information, encompassing reasoning, memory, attention and language.
- Computerized tomographic scan (CT scan) – A series of X-rays that are computer processed to make a three-dimensional image of a cross section of the brain.
- Contusion – A medical term for bruise. A region of injured tissue where there has been damage to blood vessels.
- Diffuse axonal injury – A severe type of brain injury involving tearing of the connecting fibers of the brain.
- Executive function – A neuropsychologic term that encompasses regulation of cognitive skills including reasoning, working memory, problem solving, planning, and execution.
- Gait – A medical term for describing a person’s manner of walking.
- Glasgow Coma Scale (GCS) – The most common scoring system used to objectively assess a patient’s state of consciousness. The scale consists of scoring for eye, verbal and motor responses and scores range from 3 (deep coma or brain dead) to 15 (fully awake).
- Individualized education plan (IEP) or 504 plan – A blueprint or plan that can offer individualized formal help for K-12 students with learning or attention issues.
- Lethargy – A depressed level of consciousness, consisting of severe drowsiness in which the person can be aroused by moderate stimuli and then drift back to sleep.
- Magnetic resonance imaging (MRI) – An imaging technique that uses magnetic fields and radio waves to create detailed images of the brain.
- Neuropsychologic testing – Specifically designed tests to evaluate several areas of a child’s life and functioning ability.
- Non-Steroidal Anti Inflammatory Drugs (NSAIDs) – A class of medications often used to treat pain, fever or inflammation.
- Pediatric Glasgow Coma Scale (PGCS) – A modification of the Glasgow Coma Scale used to assess the mental state of children that accounts for less developed language. A pediatric GCS of ≥13-15 is considered mild brain injury, 8-12 moderate and <8 severe.
- Phonophobia – An abnormal sensitivity to noise. An intolerance or aversion to loud noise.
- Photophobia – An abnormal sensitivity to or intolerance of light, often causing discomfort or pain to the eyes due to light exposure.
- Polysomnography – Also called a sleep study; used to help diagnose and evaluate a number of sleep disorders.
- Reaction time – The amount of time it takes to respond to a stimulus.
- Vertigo – A sensation of dizziness, imbalance or abnormal perception of movement, either of oneself or of external objects.
- AAN Sports Concussion Toolkit – https://www.aan.com/practice/sports-concussion-toolkit/
- CDC Pediatric mild TBI Guideline Workgroup – https://www.cdc.gov/injury/pdfs/bsc/systematicreviewcompilation_august_2016.pd
- Heads Up: Concussion in Youth Sports, Centers for Disease Control and Prevention – https://www.cdc.gov/headsup/index.html
- UCLA BrainSPORT – https://www.uclahealth.org/brainsport/sports-concussions
- Collins MW1, Kontos AP, Okonkwo DO, Almquist J, Bailes J, Barisa M, et al. Statements of Agreement From the Targeted Evaluation and Active Management (TEAM) Approaches to Treating Concussion Meeting Held in Pittsburgh, October 15-16, 2015. Neurosurgery 2016 Dec;79(6):912-929.
- Giza CC, Kutcher JS, Ashwal S, Barth J, Getchius TSD, Gioia GA, et al. Summary of Evidence-based guideline update: Evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;80:2250–2257.
- Halstead M ME, Walter KD, McCambridge TM, et al. Clinical report: sport related concussion in children and adolescents. Pediatrics 2010; 126: 597-615.
- Harmon KG, Drezner JA, Gammons M, Guskiewicz KM, Halstead M, Herring SA, et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med 2013;47:15–26.
- Kupperman N, Holmes J, Dayan P, Hoyle J, Atabaki S, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160–70.
- McCrory P, Davis G, Makdissi M. Second impact syndrome or cerebral swelling after sporting head injury. Curr Sports Med Rep 2012; 11:21-3.
- McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorak J, Echemendia R, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, 2012. Br J Sports Med 2013;47:250–258.
- Novak Z, Aglipay M, Barrowman N, Yeates KO, Beauchamp MH, Gravel J, et al; Pediatric Emergency Research Canada Predicting Persistent Postconcussive Problems in Pediatrics (PERC 5P) Concussion Team. Association of Persistent Postconcussion Symptoms With Pediatric Quality of Life. JAMA Pediatr 2016; Dec 5;170(12):e162900.
- Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, et al. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA 2016 Mar;315(10):1014-25.