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Understanding Concussion in Children: Diagnosis, Management & Return-to-Play Decisions - featured December 26, 2011

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Concussions in Children

By: Shahal Rozenblatt, Clinical Neuropsychologist

The article aims to provide the reader with an understanding of concussion in children, including the physical and physiological events that are involved, the cognitive and psychological consequences, and the assessment process and making safe return-to-play decisions.

Recent statistics suggest that approximately 1.4 to 3.6 million sports and recreation-related concussions are sustained each year, with most of these affecting children and adolescents who are more likely to participate in sports. According to a 2010 survey published in the Journal of the American Academy of Pediatrics, of 502,000 hospital emergency room visits for concussion across the country, 40% of the concussions reported occurred in children between the ages of 8 and 13 years with 25% of those concussions being sustained during involvement in organized sports. Football and ice hockey were the team sports with the highest rates of concussions while bike riding, skiing and playground accidents had the highest non-team sport related rates of concussion. There is a growing body of evidence showing the girls are more likely to sustain concussions than boys when they participate in similar sports. The reason or reasons for the increased vulnerability remains unclear but it has been suggested that the stronger neck and shoulder muscles of boys offers greater stability to the head during an impact. Girls also may play more aggressively than boys, or physiological differences, including hormonal differences, may make girls more susceptible to such injuries.

What is a concussion?

A concussion results from an impact to the head that causes the brain to move violently inside the skull, resulting in stretching and sheering of the brain tissue. This injury leads to a change in the metabolic processes in the brain, with a sudden increase in the need for glucose metabolism (glucose is the main source of energy for neurons or brain cells) coupled with a sudden decrease in the availability of glucose and diminished ability to process it. Although this is a simplified description of the processes involved in a concussion, this is what leads to the symptoms experienced following a blow to the head.

The signs and symptoms of concussion can be divided into three general categories: somatic, behavioral/emotional, and cognitive. Somatic complaints include headache, nausea/vomiting, balance problems and dizziness, sensitivity to light and sound, numbness and tingling, visual changes (e.g., blurred vision or seeing double), and tinnitus. Loss of consciousness occurs in only 10% of concussions. Behavioral and emotional symptoms include lethargy, fatigue, depression, anxiety, irritability, and difficulty sleeping or sleeping more than usual. The cognitive consequences of a concussion include limited attention span, memory problems, confusion, and feeling slowed down or as if one is in a fog. The extent to which each of these symptoms is experienced varies from person to person. In addition, some symptoms will arise at the time the injury is sustained, while others may take a day or two to manifest. The delay in symptom onset is one of the primary reasons why athletes, particularly children and adolescents, should not return to play immediately following a blow to the head.

A few words about second impact syndrome.

Second impact syndrome (SIS) refers to an increased vulnerability to further concussive injuries due to a prior injury. It is hypothesized that there is increased vulnerability to reduced cerebral blood flow (CBF) for an extended period (3 days in rat models) wherein the brain is unable to contend with further decreases in CBF and the hypermetabolic demands of the second concussion. The decreased supply of oxygen and sources of energy to the brain, coupled with increased demand results in greater vulnerability to the death of neurons. Loss of the mechanisms that regulate brain activity result in swelling of the brain tissue and herniation (the brain is squeezed to the side or down by pressure on the tissue), further damaging the brain. There continues to be debate about the existence of SIS and actual rates are unknown.

How do we evaluate a concussion?

In college and professional sports and in some high school settings, there is often an athletic trainer or medical professional that can conduct a sideline evaluation of a potentially concussed athlete. The sideline assessment involves determining the athlete’s status immediately after sustaining a blow to the head, which will include determining if there is a skull fracture or other serious injury that will require emergency medical care. This will be followed by assessing the athlete’s alertness (i.e., determining if there was loss of consciousness) and orientation. Orientation allows the examiner to assess the athlete’s level of confusion by asking questions such as the date and location. Amnesia for events immediately prior to the blow and following the blow is considered a fair measure of injury severity and is evaluated by asking the athlete if he or she recalls events immediately preceding and following a blow to the head. Attention and concentration are assessed by using mental tasks that require the athlete to keep information in mind and manipulate it (e.g., reciting the months of the year backwards). The examples above were obtained from the Standardized Assessment of Concussion (SAC; McRea, 2001).

There exist an increasing number of tools that are available to assess the impact of blows to the head and monitor the progression and resolution of symptoms following a concussion. They range from paper-and-pencil measures to those that can be done on computer. The latter tests are rapidly becoming the preferred way of assessing the consequences of concussion and include the Automated Neuropsychological Assessment Matrix (ANAM) which is used by the United States Army and HeadMinder, ImPACT and CogState which have been developed for the assessment of athletes ages 10 and older. Each of these measures requires between 20 and 45 minutes to administer, providing baseline and post-injury assessments of cognitive functioning. The tests are easily administered, requiring a computer and internet connection, are automatically scored and stored on a server, and allow for multiple administrations to gauge recovery. It is important to keep several factors in mind when using these tests. Although it takes little skill to administer these tests, interpretation requires a professional with training in assessment, including psychometrics and brain-behavior relationships. Particular difficulty occurs when athletes sandbag the test, meaning that they perform poorly on purpose in the hope that a future concussion will not sideline them. More common issues with the computerized tests, particularly with young children is the impact of prior medical and mental health conditions on test results. For example, children diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD) may perform poorly, not because of a concussion, but because ADHD makes attention and concentration difficult and also has an impact on memory and processing speed. It is therefore extremely important to keep the athletes effort and prior history in mind when looking at the test results.

Ideally, the athlete will have undergone baseline testing prior to participation in sports. The baseline serves as the athlete’s preinjury level of functioning. Post-injury assessments are conducted once the athlete has sustained a blow to the head to determine the symptoms and their resolution over time.

What is the treatment for a concussion?

There is no treatment per se for concussion. This means that the speech, occupational and physical therapies that are of such great importance for the recovery from other forms of brain trauma do not help in the recovery from concussion. The current clinical research shows that the most important part of the recovery process is rest. This not only means keeping the young athlete off the playing field, but reducing most types of stimulation. Think of this as the equivalent of bed rest. As has been often demonstrated, premature involvement in physical or cognitive activity will exacerbate the symptoms of a concussion. Consequently, the rule of thumb is to keep an athlete out of the game for at least a week and, in younger players, for a period of two weeks (research has shown for example that college athletes need more time to recover from a concussion than professional athletes).

Making the Return-to-Play decision.

When to allow an athlete to return to play is a difficult question to answer, but the following guidelines is based on the Consensus Statement on Concussion in Sport, 3rd International Conference on Concussion in Sport Held in Zurich, November 2008, which is the accepted standard in the field of sports medicine and concussion management. Once a concussion is sustained the athlete should be removed from the game and this is particularly so for children and adolescents. Return-to-play (RTP) should commence in a stepwise process beginning with complete cognitive and physical rest, until symptoms subside, followed by a gradual return to preinjury activity levels. This will be done under the care of a physician with input from the neuropsychologist and other individuals involved in the athlete's care. Because the recovery process is different for each person, an individual program should be put in place for each athlete who sustains a concussion. A one-size-fits-all approach is not appropriate in this instance.

The RTP protocol A gradual return-to-play protocol is implemented and the athlete progresses to the next step when he or she remains symptom free after each step is completed:
  • No activity;
  • Light aerobic exercise and conditioning;
  • Sport-specific exercise;
  • Non-contact practice drills & progressive resistance training;
  • Contact practice drills;
  • Return to play;
  • If symptoms return during any of the above steps, the athlete is typically returned to no activity.

Further Reading and Information.

Centers for Disease Control - http://www.cdc.gov/concussion/sports/index.html
National Athletic Trainers Association - http://www.nata.org/health-issues/concussion
National Academy of Neuropsychology – http://www.nanonline.org
Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury
Edited by Ruben J. Echemendia, Ph.D., Guilford Press, New York, 324 pages, ISBN-10 1-57230-078-7
Consensus Statement on Concussion in Sport 3rd International Conference on Concussion in Sport Held in Zurich, November 2008 Clinical Jrnl of Sport Medicine 2009;19:185–200).

Featured Author: Shahal Rozenblatt, Clinical Neuropsychologist

Dr. Rozenblatt is clinical neuropsychologist specializing in the evaluation and treatment of children and adults who are experiencing problems with their thinking, emotions, behaviors or relationships that are due to neurological, mental health or learning problems. He received my Ph.D. in clinical psychology in 2003 from Long Island University's Brooklyn campus and is licensed to practice psychology in New York State. He completed a 2-year post doctoral residency in neuropsychology and rehabilitation at St. Charles Hospital, in Port Jefferson, NY. He continues to serve as a staff neuropsychologist responsible for evaluating children and adults who are involved in treatment/rehabilitation following acute care of neurological illnesses, stroke or traumatic brain injury and of children and adolescents who are seeking services from the school due to learning or attention problems.

He specializes in the assessment of concussion in athletes and am a Certified ImPACT Consultant.

As a private practitioner, he continues to work with children, adolescents and adults who have neurological, psychological and learning problems, providing both assessment services and treatment. His practice has two locations: one is located in Manhattan and the other in Smithtown in Suffolk County.

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Tags: Article TBI 30 December 2011 Newsletter