Concussions in Adolescents
If you’ve been around athletics (whether watching or playing), you have most likely heard the term concussion. Although we may not realize it, concussions are a huge problem in athletics, especially concussions in children. Adolescent sport-related concussions (SRC’s) account for the majority of all SRC’s. There are approximately 1.1-1.9 million recreational concussions annually in individuals younger than 18. Within male athletics, American tackle football poses the biggest concussion risk, followed by lacrosse, ice hockey, and wrestling.
Within female sports, soccer poses the biggest risk, followed by lacrosse, field hockey, and basketball. It was found that only 40-45% of high school athletes reported their SRC’s and that 45-65% with concussions were not seen by medical professionals. Why the disparity? Most concussions either go unnoticed and undiagnosed, or simply aren’t understood to be as severe a medical injury as they are.
So, what exactly is a concussion?
According to the Concussion in sport group, a concussion is “a traumatic brain injury induced by biomechanical forces.” This can mean impact forces, acceleration/deceleration forces, and head rotational forces. There are five common features of injury that we must be aware of:
a direct blow to head, neck, face or a force elsewhere on the body that is transmitted to the head,
rapid onset of short-lived neurologic impairments,
signs and symptoms reflecting functional disturbance rather than structural injury,
multiple signs and symptoms that may not include loss of consciousness,
and everything from above cannot be otherwise explained.
Signs and Symptoms of a Concussion
In order to catch a concussion, we need to understand the signs and symptoms. There are five different categories outlined in the table with all possible symptoms listed under each one. Headache has been reported to be the most common symptoms, followed by dizziness, difficulty concentrating, and confusion. If you notice in the table above, loss of consciousness is not required to sustain a concussion. In fact, loss of consciousness was only reported in less than 5% of SRC cases.
Concussions may also cause temporary amplification of pre-existing conditions such as migraine disorders, ADHD, sleep disorders, learning disorders, and depression-anxiety disorders. Therefore, it is crucial for individuals who know the child and their medical history to keep a close eye on them in the case of a suspected concussion.
Limitations for Suspected Concussions
In the case of a suspected concussion it is crucial that individuals do not return to play within the same day, as additional impact can prolong the recovery period and increases the risk for a condition called Second Impact Syndrome. Though rare, it can lead to swelling of the brain and cause long term neurological/cognitive impairments.
A nice little slogan to go by is “When in doubt, sit them out!” However, extreme rest should also be avoided, as this increases the burden of symptoms that children may experience. Any activity participation should be light (i.e. brisk walking), and below the level that brings about symptoms. The cognitive load that children experience (i.e. schoolwork, tutoring, etc.) should be reduced but not eliminated, as studies show that individuals without a reduction have shown to take longer in their recovery compared to those who reduced their cognitive load. Individuals of driving age should avoid getting behind the wheel of a car for a few days due to a decreased reaction time that occurs with concussions, which may increase their risk for being involved in a motor vehicle accident.
Believe it or not, screen time does not need to be limited in individuals with a concussion. Their symptoms may increase, but it has been shown that there is no detrimental effect to recovery time. Cutting screen time may also be ill-advised due to the highly tech-based social world that we live in. Limiting the time on screens can limit communication with friends and social circles that may result in feelings of social isolation, depression, and anxiety.
When you have someone with a suspected concussion it is important that they be taken to a health care provider to be evaluated. Concomitant vestibular and cervical injuries have been shown to occur in most individuals suffering from concussions. Individuals that suffer from vestibular injuries along with their concussion may have gaze impairments (gaze stabilization), decreased ability to scan/read the environment/books/classroom material (saccades), and balance/dizziness impairments.
Cervical impairments can include whiplash-like injuries and cervicogenic pain and/or headaches. Schneider et. al. found that individuals who receive physical therapy for the cervical-spine and vestibular system have a higher and quicker return to sport ratio compared to those who received minimal treatment. Storey et. al. found that individuals who receive physical therapy for their concussions have a lower burden of symptoms that those who did not complete a course of care. The majority of individuals recover within one to four weeks.
Return to Sport
Physical therapy can also help individuals with their return to sport progression once they have symptom resolution. Each program created should be individualized. Each step in the program should take 24-hours to complete with out reproduction of symptoms. If symptoms return, the individual should wait an additional 24 hours and then repeat the same step. Here is a recommended return to sport program that can be followed.
https://www.cdc.gov/headsup/resources/index.html
References:
Halstead ME, Walker KD, Moffatt K. Sport-Related Concussion in Children and Adolescents. Pediatrics. 2018; 142(6): e20183074.
Danesjvar, D. H. (2011). The Epidemiology of Sport-Related Concussion. Clin Sports Med,30, 1-17. Retrieved July 29, 2019.
Narayana S, Charles C, Collins K, Tsao JW, Stanfill AG and Baughman B. Neuroimaging and Neuropsychological Studies in Sports-Related Concussions in Adolescents: Current State and Future Directions. Frontiers in Neurology. 2019; 10 (538).
Schneider KJ, Meeuwisse WH, Nettel-Aguirre A, et. al. Br J Sports Med 2014; 48: 1294-1298.
Storey, E. P. (2018). Vestibular Rehabilitation Is Associated With Visuovestibular Improvement in Pediatric Concussion. Academy of Neurologic Physical Therapy,42, 134-141. Retrieved July 26, 2019.
Nicole Laman SPT
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