Concussions in the Young Athlete

According to the 4th International Conference on Concussion in Sport held in Zurich in November of 2012, the definition is:

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilised in defining the nature of a concussive head injury include:

  1. Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an "impulsive" force transmitted to the head.
  2. Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.
  3. Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

So what does that all mean? Under the first point, they state that the impact does not have to be a direct hit to the head. Any rapid change of force to the head due to direct or indirect contact can result in the shearing force inside the skull that causes a concussion. Even if your child was not hit in the head, a concussion cannot be ruled out.

Concussions can result in numerous symptoms, but not all will be present and not all will show up right away. It is imperative in an athletic setting to have health care providers available to administer concussion evaluation screening tests in order to determine if these symptoms are present. It is equally important to administer the test repeatedly in the event that symptoms have a delayed onset. If you suspect your child may have a concussion, they should discontinue play until they are properly evaluated.

Concussions will not show up on neuroimaging. The injury to the brain is one of shearing force and energy crisis. However, it is extremely important to understand that the absence of abnormality on imaging does not mean that concussions are not serious. Concussions are a subset of a traumatic brain injury. Furthermore, your physician may request imaging to rule out other serious brain injury.

Symptoms may spontaneously resolve with time. Occasionally, symptoms persists for days, weeks, or even months. Symptoms can include headaches, sensitivity to sounds or light, dizziness, fatigue, difficulty concentrating, irritability, foggyheadedness, insomnia, among others. In the event that symptoms do not spontaneously resolve, it is important to take a multidisciplinary approach to promote full recovery and prepare them for a safe return to play.

Many healthcare providers can be involved in managing a concussion including athletic trainers, physical therapists, neuropsychologists, and neurologists. Each discipline has a crucial role in the monitoring and recovery of symptoms. A carefully graded return to play protocol is essential to resolving your child's symptoms and returning them back to sport safely.

The goal of a graded return to play protocol is to lower your child's symptoms at baseline. Once that is achieved, it is important to slowly increase the intensity of exercise. Since a concussion is an energy crisis in the brain, any increase in heart rate may elicit symptoms. The child must transition from no activity until symptoms are at baseline, to light activity, sport specific exercises, non-contact sport drills, full contact sport drills, and finally return to play. Symptoms may be present at the beginning of each stage, but should resolve before progressing to the next stage to allow the brain to acclimate to that level of activity. There may be a need for follow up neurological testing to monitor symptom progression.

In the event that your child is having difficulty progressing through the various stages, different medications may be recommended by your physician to help manage symptoms. It may also be recommended that the child limit attendance to school, social interaction, and screen time (TV and cell phone). Any visual, auditory, or cognitive demand may increase or prolong symptoms.

Experiencing a concussion can be scary and difficult. If you think your child has suffered a concussion, even in the absence of a direct hit to the head, it is imperative that you remove them from play for the rest of the day. Symptoms may be delayed for hours after injury. Your child should be evaluated by a qualified healthcare professional who can administer a concussion evaluation test. Imaging may or may not be necessary. Once diagnosed, rest is essential in the early stages to decrease symptoms at baseline. This means no school, TV, cell phones, loud music, or social interaction. Within a few days, symptoms typically diminish and a carefully graded exercise program should be implemented. Further neurological testing may be necessary to monitor your child's symptoms in response to increased exertion. Once your child has successfully progressed through the stage of a return to play protocol, they are ready to return to sport. There are many variables that can prolong or delay recovery, and each child should be treated as an individual. If you can identify when your child has sustained a concussion, you can get them on the right path towards a full recovery.

If you have any further questions on concussions, do not hesitate to contact me or one of our other qualified providers.

David Lippi-Guerron, PT, DPT
David received his Doctor of Physical Therapy degree in 2013 from the University of Wisconsin - Madison. He specializes in sports injuries and spine rehabilitation as well as vestibular and concussion management. He is current Director of the Sport & Spine Clinic Madison East.

References:
Br J Sports Med. 2013 Apr;47(5):250-8. doi: 10.1136/bjsports-2013-092313. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. McCrory P1, Meeuwisse WH, Aubry M, Cantu B, Dvorák J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA,Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M,Schneider K, Tator CH, Turner M.