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Concussion in Children: Returning to Play

In my practice, I see it frequently that a coach allowed a patient to return to play after suffering a concussion and still symptomatic. The popular movie, “Concussion” starring Will Smith, brought to light the grave damage recurrent concussions can cause on the brain to the general American population. Yet, for some, the future neurological complications pale in comparison to winning the game, being the best.

Adults in a professional league such as the NFL can make informed choices to determine if they want to place their own brains at risk. Children and teenagers cannot. Concussion is much wider spread that many previously thought. My youngest concussion patient was a nine year old girl who sustained it during a head collision playing soccer. Teens on their high school football teams fall victims many times. However, they do not all possess the knowledge at the high school level to determine when a player can safely return to play. Not all high school teams bring along their own team of doctors to every game or even have a trainer. Sometimes, it is just a coach or two making the decision. Over the past decade, return to play guidelines were developed and are now quite spelt out. It should never happen that any athlete, professional or playing PeeWee football, be allowed to return to play before the guidelines specify.

What is a Concussion?

The word concussion is derived from Latin and means literally to “shake violently”.  It is usually caused by a sudden direct hit to the head. The brain sits in a basin of fluid surrounded by the skull. The brain can sometimes move around in this fluid when it is jolted. In addition to the brain being bruised, injury can happen to the blood vessels and nerves.

What are the signs and symptoms of concussion?

  • Headache or head pressure
  • Loss of consciousness
  • Confusion
  • Amnesia regarding the trauma
  • Dizziness
  • Tinnitus
  • Nausea and/or vomiting
  • Slurred speech
  • Delayed response to questions
  • Fatigue
  • Appearing dazed
  • Impairments in memory and concentration
  • Irritability
  • Personality changes
  • Sensitivity to light and sound
  • Sleep disruption
  • Abnormalities in taste and smell
  • Unsteady gait
  • Change in eating habits

Because children and toddlers have a larger skull space to brain size, they are especially susceptible to concussion. It is more difficult to diagnose it in these ages.

The diagnosis of concussion is made by the patient’s history. A careful neurological and cognitive exam should be performed by a physician. Either a CT scan or MRI should be done to rule out other diagnoses such as intracranial bleeds.  Some patients need to be hospitalized depending on the severity of the concussion. Others can be observed at home. A person with a concussion may need to be awakened several times during the first 24 hours to ensure they are not getting worse. The mainstay of treatment for concussion is rest, both physical and mental. Children may need to stay out of school for a time because anything than requires strenuous mental activity often makes symptoms worse.

Regarding knowing when to return to play, the CDC guidelines are most often implemented. These guidelines apply to any athlete of any age, whether playing competitive or recreational sports. The decision for a younger athlete to return to play is not determined on the sidelines. Rather, it often happens in the exam room or emergency room days to weeks after the trauma. The physician must monitor both physical and cognitive activities, consider the history of concussion(s), and individualize the plan to that specific athlete. If a concussion presents to the ER, they should be referred to a healthcare provider who can follow up with them over time. The CDC recommends that no player should return to play from the ER, whether the same day or on a future date.

Return to Play Progression:

Baseline/No symptoms: The player must have completed the physical and cognitive rest and have had no symptoms for a period of 24 hours. For younger athletes, more conservative measures should be implemented.

Step 1/Light Aerobic activity: The goal here is only to increase the athlete’s heart rate and last no more than 5-10 minutes. No weight lifting, jumping or hard running should be done during this stage.

Stage 2/Moderate activity: The goal of this stage is limited body and head movement and the duration should be less than the usual routine. Activities that can be included here include moderate jogging, brief running, moderate intensity stationary bike, and moderate intensity weight lifting.

Stage 3/Heavy, non-contact activity: The goal of this stage is to increase the intensity but still avoid the contact. The athlete should be nearing his/her usual routine. Activities that can be included here include running, high intensity stationary bike, the athlete’s regular weight lifting routine and non-contact sport specific drills.  This stage may add some cognitive component.

Stage 4/ Practice and full competition: The goal here is to return to full contact practice.

Stage 5/Competition: The goal here is to return to competition.

These stages are not meant to be completed in days’ time but rather over a period of weeks to months. It is very important to continue monitoring neurologic and cognitive functioning. The athlete should only progress to the next stage when there are no symptoms present. If symptoms do develop, the athlete should return to rest. When he/she remains asymptomatic for 24 hours, then he/she can resume activity at the previous stage.

If the patient has worsening symptoms at any time or the symptoms did not resolve after 10-14 days then a referral should be made to a specialist. Additionally, if the patient has a history of recurrent concussions or other underlying factors,  a specialist referral is appropriate.

While the guidelines are carefully defined, we live in a society where there is pressure to excel, and return to play, The guidelines sometimes get put on the sidelines in the rush for victory. According to Hall of Fame running back Eric Dickerson, “You are supposed to be tough. You are supposed to play through pain. You are not supposed to cry. We are taught that early on in the game as kids. Tough sport. Brutal sport. It’s like the gladiator. People want to see big hits. They wind up on Sports Center. And as a player, you don’t want to admit that you are injured”. Other players were quoted as saying that they hide concussions to keep playing. But at what cost? We now know that repeated concussions can lead to chronic traumatic encephalopathy. When will the brains of these players in the pros be more valued than their tackling skills?

And it us not just professional athletes feeling the pressure. I see it many times in my practice when the father of a quarterback at the local high school wants him to be rushed back into the game so the school doesn’t lose the championship. I see it when the coach of the local soccer team calls and tells me “the kid looks good, we need him tonight”. I see it every time a coach rushed an athlete with a concussion back into the game without any medical attention at all. Really, is a high school football championship so much more important than your child’s healthy brain? Please don’t ask me to abandon the guidelines to produce a champion, I will always say no. Someone needs to protect these young athletes’ brains. Will you?

Linda Girgis MD, FAAFP is a family physician practicing in South River, New Jersey. She was voted one of the top 5 healthcare bloggers in 2016. Follow her on twitter@DrLindaMD.

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