An international panel of neurologists, updating their recommendations on concussion care, now recommend that any athlete eighteen or younger who is believed to have sustained a concussion during a game or practice should never be allowed to return to the playing field the same day.
The group had previously recommended that athletes could return if cleared by a doctor or certified athletic trainer, but now suggest that it is impossible to make immediate accurate assessments after the injury. It can be dangerous for an athlete to return to the game too soon.
The general consensus of experts is that children and teens require different treatment for concussion. Though 80 to 90 percent of adult concussions resolve in seven to ten days, the recovery time is often longer for children and adolescents. In all cases, the decision to allow an athlete to return to play should be made based on the individual’s progress, not a specific period of time. Careful post-concussion evaluation of the injured student-athlete is essential.
What is a concussion?
A concussion is a brain injury that temporarily alters brain functions. It usually is the result of a direct blow to the head, but it also can be the result of a blow elsewhere on the body that has sufficient force to affect the head. Most young people are not knocked out during a head injury, and many do not experience any memory loss. Often, a concussion does not show up on an MRI or CT scan.
After any hit to the head, it’s important to watch the athlete for any symptoms or signs of a concussion. Symptoms fall into four categories:
- Cognitive – confusion, disorientation, memory loss, slow to answer questions and follow commands, easily distracted
- Physical – headaches, nausea or vomiting, dizziness, clumsiness or balance problems, blurry vision, poor coordination, sensitivity to light or noise, or loss of consciousness
- Emotional – nervousness or anxiousness, sadness, irritability or mood swings, inappropriate behavior
- Sleep problems – difficulty falling asleep, frequent waking at night, fatigue or tiredness during the day
Adolescents with concussions heal more slowly than adults. Concussions in young people can last weeks or months. Symptoms of concussion can interfere with school and social activities as well as personal relationships. Athletes who have had a concussion are at least twice as likely to suffer another one. Each concussion must be treated individually, and athletes who suffer multiple concussions have more problems with recovery.
Potential long-term complications of concussion
One reason return-to-play guidelines are so important is that the long-term effects of concussions in children can be considerable. Post-concussion syndrome is defined as, “Three months’ duration of three or more of the following symptoms: fatigue, disordered sleep, headache, dizziness, irritability or aggressiveness, anxiety or depression, personality changes, and/or apathy.”
Studies suggest that athletes who sustain a series of concussions over time (especially three or more) are more likely to have numerous post-concussive symptoms, including amnesia and confusion.
What do the new guidelines suggest?
Any athlete with a concussion should stop playing immediately. He or she should never return to any activity (even jogging or weight lifting) the same day the concussion happened. This is important even if the symptoms last for fifteen minutes then seem to go away. Any athlete with a concussion should be evaluated by an appropriate health care professional before returning to activity.
The new guidelines recommend that children and teens must be strictly monitored and their activities restricted until they are fully healed: no return to the field of play, no return to school, and no cognitive activity.
The guidelines also point to several important points for parents, coaches, teachers, and health care providers:
- Injury to the developing brain, especially repeat concussions, may increase the risk of long-term effects in children.
- Children and adolescents may need a longer period of full physical rest than adults after a concussion, and they require a gradual return to normal activities when completely healed
- For children, “cognitive rest” is a key to recovery, including limits on cognitive stressors such as academic activities and at-home/social activities including text messaging, video games, and television watching.
The return-to-play protocol recommended by the American Academy of Pediatrics progresses in a step-wise fashion. Each step should take at least twenty-four hours. Returning symptoms indicate inadequate recovery, and the athlete should wait an additional twenty-four hours before attempting the previous step again. Symptoms generally resolve within a week to ten days, but athletes with persistent symptoms should be reevaluated by a doctor.
Here are the steps:
- The athlete must observe complete physical and cognitive rest while symptoms are present.
- Once the athlete has stopped showing any symptoms, he or she can progress to light aerobic activity.
- Provided symptoms don’t return, activity may increase to sport-specific exercises without head impact.
- The athlete may advance to more complex, non-contact drills.
- The athlete may advance to full-contact practice.
- The athlete may advance to normal game play.
What can parents do to prevent recurrent concussion and long-term complications?
The first step in preventing concussion and the long-term risks of recurrent concussion is for parents to know the risks associated with their children’s sport. Among high school sports, football has the highest reported concussion rate. The second highest risk is girls’ soccer followed by boys’ lacrosse and then boys’ soccer, and finally girls’ basketball. There is no information available for individual sports such as skateboarding, snowboarding, or mountain biking.
Second, parents should make sure their children wear appropriate headgear and other protective equipment and follow the rules of the game. Make sure athletes are not hitting with the tops of their heads. The point of impact should be the shoulder, the front of the body, or the hands. The rule is: You must be able to see what you’re hitting!
Third, err on the side of caution when deciding when a concussed athlete should return to play. When in doubt, sit the child out.
Finally, educate others. Both parents and coaches should understand the serious nature of a concussion.
Additional information on concussion guidelines in student athletes may be accessed through Massachusetts Interscholastic Athletics Association.