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Post-Concussion Care Recommendations for Children’s Sports Injuries Are Often Inadequate

Concussion

In tandem with recent media attention to concussions in professional sports, the American Academy of Pediatrics presented a detailed report on concussions in youth sports at its recent national conference in Orlando.

The report, titled “Returning to Learning Following a Concussion,” discusses results from various studies, and its authors call for cognitive (mind) rest following a concussion, instead of just physical rest.

Lead author Mark Halstead, MD, FAAP, stated that children who have suffered a concussion may have trouble learning new things or remembering what they have learned; he added that returning to academics too soon may worsen diverse concussion symptoms or even prolong recovery time.

The authors of the report called for pediatricians, school officials and parents to work as a team in assessing a child’s health status following a concussion, and to be willing to make adjustments in the school setting and in academic requirements, to give the child time to fully heal and facilitate their return to learning.

A review of concussion cases that was discussed at the AAP meeting found that 25 percent of all children who sustain sports-related concussions do not receive appropriate discharge instructions from emergency departments. And while many doctors recommend physical rest for patients, only a small percentage (estimated in a study at between 4 and 12 percent) address cognitive rest. A retrospective study cited at the meeting also found that about a third of concussion patients were discharged without specific instructions for a follow-up.

Since 2010, the Centers for Disease Control and Prevention (CDC) have offered an online concussion education program, which includes a fact sheet with a detailed list of possible concussion symptoms, ways to prevent concussions in youth sports, and recommended instructions upon discharge from hospital emergency departments. The CDC developed this site for sports coaches and trainers; the program takes about 30 minutes and can be completed by anyone (it can be found at: www.cdc.gov/concussion/headsup/online_training.html).

Mark Riederer, MD, of the University of Colorado, who reported on studies at the AAP meeting, called on pediatricians to partner with emergency departments to review and even rewrite, if necessary, discharge instructions, as a strategy for improving current discharge recommendations.

What Is a Concussion?

A concussion is defined as any injury to the brain that disrupts its normal function, temporarily or permanently. Concussions are a type of traumatic brain injury (TBI). All concussions are considered serious and should be evaluated by a physician. While many concussions involve loss of consciousness, a concussion can also occur without loss of consciousness.

Concussions can happen in any sport; they can be caused by a bump, blow or jolt to the head. They can also occur when a blow to the body causes the head and brain to move back and forth quickly; this causes the brain to bounce or twist within the skull. The sudden forceful movement can cause brain cells to stretch or even tear, damaging the cells and causing chemical changes in the brain.

Because most children and adolescents look normal after a concussion, school personnel may not recognize the need to make academic or environmental adjustments for the child. This is where a pediatrician can give the school team (teachers and coaches) valuable guidance about how to proceed with each individual concussion case, as well as perform cognitive tests on the child if needed, to determine whether the child’s brain is ready to resume learning. All concussions are different, so it is unadvisable to use the same approach in dealing with children who have suffered concussions.

With respect to signs and symptoms of concussion, these usually appear soon after the injury; but they may also not be noticeable for hours or even days. Common physical and cognitive concussion symptoms include:

  • Headache or feeling “pressure” inside the head
  • Temporary loss of consciousness
  • “Seeing stars” (a fitting analogy, as a strong impact to the head can actually make a person “see” white, star-shaped objects on a dark background)
  • Nausea or vomiting
  • Decreased coordination or balance
  • Double or blurred vision
  • Weakness
  • Numbness
  • Confusion
  • Slurred speech
  • Sensitivity to light
  • Sensitivity to noise
  • Appearing dazed or mentally foggy
  • Having trouble remembering events just before or after concussion, or other memory problems that were not pre-existing
  • Sleeping more or less than normal
  • Fatigue

These are some of the physical and/or cognitive symptoms. Cognitive symptoms may take longer to go away than physical symptoms and should be assessed ongoingly by a specialist. Further, concussions can cause a child emotional difficulties, including nervousness, moodiness, irritability and depression. These are also not discussed very frequently by medical professionals and should be given attention when they do occur. If emotional issues from a concussion are getting in the way of your child enjoying life and they persist longer than a month, talk to your pediatrician about possible solutions.

In the home, if your child was concussed and you notice that the signs or symptoms have gotten worse, or you see changes in the child’s behavior or personality, contact your child’s doctor right away. If loud music or use of computers or television produce symptoms, the child should take a break from these activities, as well.

The young athlete should wait until all symptoms have disappeared before returning to his or her sport, even when they feel better and are eager to get back into things. Most young concussion victims will recover within three weeks’ time. Any concussion symptoms that return upon exertion indicate that the concussion is not yet fully resolved. Final clearance to return to full activity should be given by a physician.

One of the key reasons that it is important not to return a child who still has concussion symptoms to his or her sport is the greater likelihood of a second concussion taking place. Repeat concussions — those occurring within hours, days or weeks of the first — can slow down recovery, produce long-term problems or cause serious complications such as brain swelling, permanent brain damage or even death.

By Jamell Andrews

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