As experts in pediatric care, concussions are of enormous concern to us.
The American Academy of Pediatrics (AAP) has reported that emergency room visits for concussions in children ages 8 to 13 years old has doubled, and concussions have risen 200 percent among teens ages 14 to 19 in the last decade.
At ANA, we are most alarmed by the increase in the number of concussions, as well as multiple concussions and second-impact syndrome (a dangerous condition in which a second concussion is incurred before the symptoms of a first concussion have subsided). Equally disturbing is the fact that proper management of concussions continues to be problematic, although it has been estimated that up to 3.8 million recreation and sports-related concussions occur annually in the United States. Concussions represent nine percent of all high school athletic injuries, and statistics for grade school and middle school athletes are underreported.
A concussion is a traumatic brain injury (TBI) that results from a variety of causes, such as a direct blow to the head, a fall or a whiplash-type trauma. These can occur with a sports-related injury, a motor vehicle accident or a slip-and-fall scenario, among others. A concussion affects brain function, although usually only temporarily.
Symptoms of a concussion usually reflect a functional disturbance to the brain and may include physical (e.g., headaches, nausea), cognitive (e.g., difficulty with concentration or memory), emotional (e.g. irritability, sadness), and ‘maintenance’ (e.g. sleep disturbances, changes in appetite or energy levels) symptoms.
Symptoms may not occur until several hours after the episode and many young athletes may not be forthcoming with their symptoms, for fear of activity restrictions. 90% of most diagnosed concussions do not involve a loss of consciousness. An unconscious athlete or one who regains consciousness quickly may be evaluated further on the sidelines.
Signs of a concussion may include:
It is important to note that ninety percent of most diagnosed concussions do not involve a loss of consciousness, and symptoms may not occur until several hours after the episode. Even when they appear, if it’s sports-related, many young athletes are not forthcoming for fear of activity restrictions. An unconscious athlete or one who regains consciousness quickly may be evaluated further on the sidelines.
In the past, the recommended system of concussion evaluation included grades: Grade 1 (mild), Grade 2 (moderate) or Grade 3 (severe). These guidelines were developed for sports injuries by the American Academy of Neurology (AAN) in 1997. Grades were assigned specific symptomatic signs, with each grade dictating the course of action.
These three grades of concussions were characterized as follows: Grade 1 was characterized by transient symptoms and Grade 3 was the most serious and requires immediate medical attention.
However, in 2013, the AAN issued new evidence-based guidelines regarding evaluation and management of sports concussions which were published in the journal Neurology. The new recommendations are based on a review of decades of literature and were determined by focusing on four questions established by the AAN.
They were developed by a multidisciplinary committee of experts and endorsed by a wide range of athletic, medical and patient groups. The essence of these new guidelines is that concussions and return to play should be assessed in each athlete individually. Also, there should be no set timeline for safe return to play.
The updated version recommends that suspected concussions be addressed by immediately removing athletes from the game/activity. Athletes are not allowed to return until they are evaluated by a licensed healthcare professional trained in concussion management. Return to play should only be done after all acute symptoms are gone, and even then, that return should be done slowly. The younger the athlete, the more conservative these steps should be.
Licensed health professionals trained in treating concussion should look for ongoing symptoms (especially headache and fogginess) and a history of concussions, with extra vigilance when it comes to younger athletes.
The AAN guidelines point out that concussions are a clinical diagnosis (i.e., based on signs and symptoms) and that there is no single test equipped to determine diagnostic standards. Therefore, while concussion assessment tests (including written and/or computerized versions) may be helpful tools in the diagnosis and management of concussions, they should not be relied upon as sole measures.
The seriousness of a concussion dictates what kind of treatment you should seek. Most people with concussions recover fully with appropriate treatment. Make sure there is qualified personnel at sporting events who knows how to evaluate participants for concussions. These experts have a variety of tools to determine the presence of concussions on the spot. Since a concussion can be serious, safeguarding yourself is important.
Regardless of the level of concussion severity, the brain requires a certain amount of recovery. That’s because the risk of secondary (additional) concussions can seriously exacerbate the damage caused by the initial concussion. According to the AAN, the risk of repeat concussion is greater in those with a history of one or more previous concussions. In addition, the first 10 days following a concussion are the riskiest for being diagnosed with another concussion.
Once a serious injury has been ruled out, the two main components of concussion management include:
There is some controversy on the topic of rest and return to activity. Some experts question whether long periods of total rest and inactivity promote concussion recovery. They go as far as to say that some type of activity can be resumed after a day or two of post-concussion rest. Others point to the need for clarity on what constitutes “rest.”
That said, there is a wide acknowledgement of the need for professional evaluation. And experts agree that the rule should always stand that resumption of contact sports participation should occur only with approval from a physician.
If you suspect someone under your care may have a concussion, it is important to keep a close eye on the individual and call a medical professional if you notice any concerning symptoms. If you are unsure whether or not to call a medical professional, it is important to be on the safe side due to the dangerous nature of concussions.
As neurosurgeons, one of our central roles is the evaluation and treatment of mild and severe traumatic brain injuries. Please contact our office immediately if someone under your care needs medical attention for a concussion, and we will work with you to ensure the individual receives the care he or she needs.