Thanks to Julie Mankinen, PT, OCS, FAAOMPT of Austin’s Symmetry Physical Therapy for this guest post on an important topic. Julie has been practicing in Austin since graduating from Texas State’s Physical Therapy Program in 1997. In addition to being recognized for over 10 years as an Orthopedic Certified Specialist by the American Physical Therapy Assocation’s Board of Specialty Practice, Julie is a 10-year Fellow of the American Academy of Orthopedic Manual Physical Therapists.
Concussions are in the news. Professional football players are retiring early, rather than risk head injury and the potentially long-lasting health consequences that can occur thereafter. International organizations such as soccer’s FIFA are considering and implementing new policies to better protect their players. And incidences of concussion in youth athletes are being documented more widely – resulting in public recognition that athletes of all ages and in multiple sporting arenas are at risk for this type of injury.
Here are five things parents need to know about concussions and kids:
#1 Concussion does not necessarily mean a loss of consciousness or a direct blow to the head.
Essentially, concussions are ‘whiplash’ injuries, where the brain bounces around in the bony skull. This type of injury can result from a blow to the head, but can also occur when the head jerks around because of impact to the body. Although concussions have been documented most frequently in football, activities such as soccer, wrestling, basketball, cheerleading, martial arts, skate-boarding, rodeo, and even completely informal activities like tree climbing or bike riding also have the potential for head injury.
When a concussion occurs, there is a rapid onset of neurological impairments. The most common symptom reported after a concussion is dizziness. Frequently, there are also complaints of headaches, mental confusion, visual disturbances, or amnesia. Some symptoms of a concussion typically occur immediately after an injury. However, other symptoms may develop gradually – over the course of 1-2 days after the initial event. Many symptoms resolve themselves immediately, but some linger.
It is common for the symptoms of a concussion to reappear during times of exertion or stress – even after the initial symptoms have improved. Difficulty concentrating, sleep disturbances, mood changes, and fatigue or low energy levels can be reported during the days, weeks, or even months following a concussive injury.
#2 Concussions can have cumulative and long-lasting effects.
Concussions have been found to have an additive effect. That means that after sustaining an initial concussion, the risk of another similar injury is higher. In addition, someone who has had a concussion can experience more damage with less force if reinjury occurs.
The risk of other musculoskeletal injury is also theoretically higher after a concussion. Visual and balance deficits that may be present after a concussion can certainly impact coordination and movement planning – putting a person at a higher risk for falls or other sport-related injuries.
Post-Concussion Syndrome is the name given to symptoms that persist after a head injury for a prolonged period of time. In this situation, migraine or ‘tension’ headaches, sleep disorders, irritable moods or argumentative behaviors are reported for months or even years after a head injury.
Longer-term health consequences of repeated head injury are also being studied. There appears to be a relationship between head injury and memory issues later in life. Studies of retired football players have demonstrated a higher incidence in this population of symptoms similar to those seen in patients with Alzheimer’s disease or diseases like Lou Gehrig’s disease. Declines in memory and mood, as well as changes in personality, have been reported in patients whose brains have later been studied.
#3 Kids have a higher risk of concussion than full-grown adults.
Kids are more likely than adults to be participating in activities that put them at risk of getting a concussion. In addition, the brains of children are still developing. They lack the “insulation” to cushion nerve fibers adequately from certain types of impact. Kids’ brains are also smaller and lighter than adult brains, meaning less force is required to put children’s brains in motion, and therefore a brain ‘whiplash’ injury is easier to provoke. Kids’ heads are also often disproportionally larger in relation to their bodies than an adult’s. A larger head on a relatively less muscularly developed neck can also set up a situation where it is easier for a brain to get jostled and potentially injured.
In addition to being at a greater risk to get a concussion, recovery times tend to be longer for a child than an adult. While this slower recovery period is ongoing, a child has a greater risk for a second injury and for the cumulative effects of brain injury to occur. Lastly, girls tend to require longer recovery periods after a concussion than boys. This may be due to different hormonal levels or to different metabolic needs. For both boys and girls, there is risk of returning youth athletes to activity too soon – particularly if post-concussion symptoms are not carefully monitored.
#4 Coordinated medical care after a concussion is critical to enable the safe return to activities.
What should be done if a child is thought to have sustained a concussion? First, the child should be REMOVED FROM PLAY. They should not be allowed to return to activity on the same day. The child should be closely monitored for 48 hours to watch for the development of additional symptoms. The child should be referred to a health-care professional who can more fully evaluate their symptoms and assist in the coordination of their post-injury care.
Every concussion is not an immediate medical emergency. In fact, it is typical that there are NO ABNORMAL FINDINGS on brain scans like an MRI after a concussion has occurred. However, you should seek emergency medical attention if you notice any of the following DANGER SIGNS:
- Loss of consciousness persists
- Athlete is significantly drowsy or cannot be awakened easily
- Weakness, numbness, or decreased coordination is evident
- Vomiting is repeated
- Speech is slurred
- Seizures or convulsions are occurring
- Athlete is behaving unusually
When a concussion does not require emergency medical care, it is still important for an injured athlete to be evaluated by health-care practitioners familiar with the management of concussion. Ideally, this would involve a multi-disciplinary team. A physician may be needed to rule out emergency medical situations, such as a skull fracture or other need for medical stabilization. A physical therapist that deals with sports injuries is also a good resource. A physical therapist can screen the athlete for cognitive function (memory), balance, visual function, and global movement strategies. A physical therapist can also then work with the injured athlete and their parents, coaches, teachers, and trainers to develop and implement a plan for the athlete’s gradual return to scholastic and athletic activity.
After a concussion has occurred, it is important to REST. This allows the brain to repair itself after injury. Both physical and mental rest are important. There is some debate over exactly how much normal non-athletic activity, such as participation in school activities or use of electronic devices, should be allowed in the days and weeks immediately following a head injury. Every concussion is different, as is every individual’s response to injury. This makes it difficult to establish specific global guidelines for post-concussion care. A good general rule of thumb is to watch for the recurrence of symptoms, and to limit any activity that is causing symptoms to recur. This requires coordination between parents, teachers, and school administrators. Good communication is important.
The determination of when a child is ready to return to play in an athletic arena is also a process that needs to be individualized for each injury. A child that has sustained a concussion should not be returned to normal levels of activity participation until they have successfully completed a progression of activity WITHOUT showing any symptoms. After a phase of rest, the child should be directed through and monitored during a phase of light aerobic activity, and then subsequently through light sport-specific exercise, non-contact sport drills, and then full-contact or full-intensity practice. Once all of these phases are completed satisfactorily, the decision to return an athlete to play can be made via the collaboration between all members of the multi-disciplinary support team.
#5 Protective equipment has NOT been shown to reduce concussion risk.
There is, unfortunately, no solid evidence that helmets, facemasks, and mouth guards reduce the risk or incidence of concussion. This equipment has been demonstrated to limit the risks of other sports-related injuries, such as skull fractures or injuries to the face, eyes, or teeth. Therefore, the use of such equipment is certainly a good practice. However, it is wise to make sure athletes and their coaches, trainers, and parents are all aware that the use of such protective equipment is NOT a sound concussion prevention strategy.
There IS some evidence that enforcement of the rules of a sport and of fair play procedures in general can contribute to the reduction of sport-related injuries, including concussions. This practice can be supported both on the field and on the sidelines by athletes, coaches, parents and fans alike.
Several other concussion prevention strategies are recommended by the US Centers for Disease Control and Prevention and the US Department of Health and Human Services. These include:
- Work to counterbalance the ‘Culture of Resistance’ that encourages playing through pain and underreporting injury
- Wear seatbelts
- Use appropriate seating in cars while kids are < 4’9”
- Wear properly fitted helmets during high-risk activities (skateboarding, bike riding, etc.)
- Utilize appropriate equipment during sports
- Establish concussion policies and action plans
- Educate athletes, parents and coaches
- Monitor the health of athletes through medical screening
The US Centers for Disease Control has developed a program, HEADS UP, that provides a wealth of additional information about concussion prevention, recognition, and medical management and is an excellent resource for athletes, parents, schools, coaches, and health care providers.
Thankfully, the increase in interest in concussions among adults is leading to an improved understanding of the ways we can prevent and treat concussions in our kids, both now and in the future.